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Imaging Payer Hassle Form

Please Complete and Email to hmccants@acc.org or Fax to 202-375-6847

What kind of Comment would you like to send?
___ Complaint
___ Problem
___ Suggestion

Please Provide the Following Information (*Mandatory):

Full Name*:  _____________________________________________________

ACC Member Number:  _____________________________________________________

Office Address*:  _____________________________________________________

City*: _____________________________________________________

State*: _____________________________________________________

Zip Code*: _____________________________________________________

Office Phone Number: _____________________________________________________

Fax Number: _____________________________________________________

Email*: _____________________________________________________

Contact Person (If Different): _____________________________________________________

Name of Health Plan: _____________________________________________________

Type of Plan/Carrier:

 ___ Managed Care Plan (Commercial)
 ___ Medicare Managed Care Plan
 ___ IPA
 ___ PPO
 ___ Commercial Insurance
 ___ Medicare
 ___ Medicaid
 ___ CHAMPUS
 ___ Worker’s Compensation
 ___Other: Please specify:


Type of Modality:
___ Cardiac CT
___ Cardiac MRI
___ Electrocardiography
___ Echocardiography
 ___ Transesophageal Echocardiography (TEE)
 ___ Stress Echocardiography
 ___ Contrast Echocardiography
___ Nuclear Imaging
___ PET
___ Coronary Angiography

Type of Problem:
___ Delay in Payment
___ Denial of Claim
___ Pre/Post Payment Review
___ Denial of Preauthorization
___ Medical Necessity Review
___ Denial of Referral
___ Utilization Review
___Other: Please specify:  _____________________________________________________

Please provide a brief description of your experience with preauthorization procedures:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


Related CPT Codes: ______________________________________________

Other (Specify): _________________________________________________
 _____________________________________________________

Is this a…
___ First time problem?
___ Recurring problem?
___ Time sensitive?

Have you contacted your local ACC Chapter?  ___ Yes ___ No

Please specify how we can be of any further assistance:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


The best way to reach me is:
___ Fax ___ Phone ___ Email ___Other: Please Specify:

You may contact the Payer Advocacy Department with any further questions at (800) 253-4636.

 

 

 


 

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