Payer Issue Reporting Form

Practice Issue Reporting Form

Please use this form to report issues that you have encountered that you think ASAM staff should know about. We will keep track of these reports to see if patterns emerge or to respond to your issue.

First Name

Last Name

ASAM member status

Email

Your Organization Type

City

What state is your practice located?

Your practice's geographic location

Your specialty

Best daytime phone number

Is this a payer issue?

Other Issues

Patient is unable to get prescribed medication from the pharmacy due to inventory issues

Pharmacist refused to dispense medication

Coding issue

Telemedicine

State/federal regulatory issue

Other...

Payer Type

Medicare Fee-for-service (FFS)

Medicare Advantage

Medicaid FFS

Medicaid Managed Care

Commercial

TRICARE

CHAMPVA

Multiple payers

Insurer/Payer name

What type of issue are you having?

Please describe the issue in detail.

Upload files

Please upload any files/documentation that you think would be helpful to share with ASAM staff.

Add another

Check this box if you would like a member of the ASAM staff to follow up with you about this comment.

I request follow up from ASAM staff.

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Practice Issue Reporting Form