New Haven County Medical Association

 

Hassle Factor Log Form

 

The New Haven County Medical Association, through its Third Party Payors Committee, 
is helping to resolve managed care issues facing physicians.  
If you would like to submit a problem or issue to NHCMA, 
please complete the following form.

 

Physician Information:

Physician Name
Practice Name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Office Phone
FAX
E-mail

Contact Person:

Name
Work Phone

Date submitted:

-- mm/dd/yy

Request in relation to (check all that apply):

Medicare Medicaid Workers' Comp
Medicare HMO PPO IPA
HMO - Commercial Commercial Insurance CHAMPUS
Other

Name of Carrier or Agency:

Dollar amount in dispute:

Type of problem (check all that apply):

Denial of Preauthorization Missing Support Documents
Denial of Referral Missing Claim Information
Denial of Claim Telephone Always Busy
Delay in Payment Excessive Telephone Hold Time
Pattern of Late Payment Request for Copy of Medical Record
Pre/Post Payment Review Request for Operative Report
Down Coding/Recording of Claims Other Documentation Requests
Lost Claims Numerous Calls for Single Claim
Inaccurate Data Entry by Insurer Inconsistent Response

Other (specify):

Brief Description of Problem:

             

IMPORTANT:  Forward copies of relevant documentation including claim, explanation of benefits, and any correspondence to: NHCMA Third-Party Payors Committee, 515 Highland Avenue, Cheshire, CT 06410.  Please be advised that the Association may share this information with the insurance carrier, relevant state agencies, or other parties to expedite resolution of your problem.  The submission of this form and any forwarded information is consent to release this form and information, as appropriate, by NHCMA.
Copyright © 2008 New Haven County Medical Association