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.