BARRIER TO TREATMENT ACCESS REPORT FORM
 

 
CSAM is initiating a project to monitor and address barriers to substance use disorder treatment resulting from denials or non-authorizations by patients' third party payers, including managed health care insurance companies, Medi-Cal, and Medicare. When a CSAM member becomes aware of such a denial or non-authorization, he/she is invited to complete a Barrier to Treatment Access Report Form and submit it for review and possible action by CSAM's Access to Treatment Committee.

1. Reason for treatment barrier:

2. Third party payer: Managed Care?

3. Third party payer:

4. Are you a network provider for this third party payer?

5. Patient Information: [Note: Do NOT use patient's name. Include patient's policy #]
Identifier:

6. Dispute/Complaint:

For example:
What treatment service was requested from the third party payer (be specific)?
What was the outcome of the treatment request?
What clinical information justified your treatment request (be specific)?

7. If you received a FORMAL denial, did you appeal to the fullest extent possible, including an Independent Medical Review?

8. Have you filed a complaint or grievance with the third party payer, the CA Dept. of Managed Health Care, or the CA Dept. of Insurance?

9. What are you hoping for CSAM to address with this case?

** Please attach COPIES of relevant documents related to this case, such as denials, letters, bills, and explanations of benefits to CSAM email: CSAM@compuserve.com or by fax (415) 764-4915
CSAM cannot return original documents.

10. Provider Contact Information: