*1. Approximately how many Child Health and Disability Prevention (CHDP) screens do you perform per month?
*2. Approximately how many Confidential Screening/Billing Report (PM 160) forms (green or brown) do you submit per month?
Green: Brown:
*3. What percentage of children receiving Child Health and Disability Prevention (CHDP) services from you do you estimate are enrolled in a managed care plan (MCP)?
25% 50% 75% 100%
*4. What percentage of children receiving CHDP services from you do you estimate are enrolled in the Medi-Cal fee-for-service program?
*5. Are you currently approved to submit Confidential Screening/Billing Report (PM 160) claims electronically?
Yes No
*6. How do you currently submit PM 160s?
Electronic Paper Both
*7. How do you complete PM 160s for paper submission?
Type Use Computer Handwrite
8. If you selected "Both" on question 6, please indicate the percent of electronic and paper claims that you currently submit. If you submit only electronic or only paper, you do not need to complete this question.
Paper percent:
* 9. If you do not submit PM 160s electronically, please select the reason(s) that you do not.
Local county CHDP program does not accept PM 160s submitted electronically or requires paper submissions
My MCP does not accept electronic PM160 information or requires paper submissions
It is easier to complete the PM 160 manually and mail the document
I did not know you could submit PM 160 claims electronically
I don’t know how to submit PM 160 claims electronically
Using a CHDP vendor to submit CHDP claims is too expensive
Other (please specify):
*10. If you submit electronically, do you use a CHDP vendor to submit PM 160s?
Yes No No, but I would consider doing so
*11. If you use a computer to complete the PM 160 for paper submission, do you use a particular software designed for the PM 160?
Yes No If yes, what is the name of the software?
*12. Are you still using a DOT matrix printer for the PM 160?
13. Please share any suggestions for changes to the CHDP claim submission process.
