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ASAM Criteria Incident Report Form for Patients and Providers

ASAM Criteria Incident Report Form

If you are a Patient, Family Member or Provider of Services concerned that treatment is being denied a patient or loved one, please complete this form

Are you completing this Report as a


(print/type)

Contact Information

1. Reason for Incident Report (check all that apply)











2. Third party payer or funding agency:
Or


3. Are you an insured member, or representing an insured member, of the insurance company or MCO involved?

4. Are you a network provider for the insurance company or MCO involved?

5. Patient Information:

Note: Do not use patient's name. Include patient's policy #.
For example: What treatment service/level of care was requested to access or be authorized and paid for, or to be provided (be specific)? What was the outcome of the request? What clinical information justified your treatment request (be specific)?
7. If your concern is with an insurance company or Managed Care Organization (MCO) and you received a formal denial, did you appeal to the fullest extent possible, including an Independent Medical Review or Independent Review Organization?

8. If a concern with an Insurance company or Managed Care Organization, have you filed a complaint or grievance with the third party payer, a state Dept. of Managed Health Care or its equivalent, or a state Dept. of Insurance or its equivalent?

(Currently, ASAM is focused on gathering data to assess what resources would be necessary to actually begin advocacy and conflict resolution.)

10. Send copies of relevant documents related to this case, such as utilization review criteria, denials, letters, bills, and explanations of benefits. ASAM cannot return original documents.

Mail, fax or email this form and any attachments to:
BRENDAN MCENTEE
AMERICAN SOCIETY OF ADDICTION MEDICINE
4601 North Park Avenue
Upper Arcade, Suite 101
Chevy Chase, MD 20815-4520
Fax: +1 301.656.3815
bmcentee@asam.org