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ASAM Criteria Incident Report Form for Payers and Managed Care Organizations (MCO)

ASAM Criteria Incident Report Form

If you are a Payer or Managed Care Organization concerned that a treatment provider is not implementing the "spirit" or content of The ASAM Criteria, please complete this form.

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






Type



3. Is the program or treatment agency in your provider network?

(Note: Do not use patient's name. Include patient's policy #)
Example: What treatment service/level of care is not provided by the treatment agency (be specific)? How is the provider not utilizing the spirit or content of the ASAM Criteria? What clinical information was not provided by the treatment provider to allow a utilization review decision (be specific)?
6. Have you addressed your concerns about the provider or treatment agency with Quality Assurance or Quality Improvement departments of the State or County licensing and accreditation organization?

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

8. 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