Payer Hassle Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Payer Hassle Form

To better collect data for the MS Division of Medicaid and other payer groups, the MSAAP is asking that Providers who have issues or concerns to submit them in the form below. This does not replace the channel of communication between the MCO or other groups and the Provider.

Which MCO or PPO are you currently experiencing payor issues with? (If multiple, please complete a form for each.)

Blue Cross Blue Shield

Magnolia

Molina

United Health Care

Other:

Clear selection

What is/are the issues with the above selected MCO/PPO?

Incorrect denial of claim line(s)

Incorrect denial of authorized service

Code or modifier issue

Medical necessity

Incorrect rate payment

Other:

Clear selection

If needed, briefly expand the issues indicated above. Please be specific (i.e. codes affected, etc.)

So we can follow up with you for further information if needed, please provide your name and contact information (e-mail/phone).

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Mississippi Chapter - American Academy of Pediatrics.

Does this form look suspicious? Report

Forms