Third Party Payor Issue Form Question Title * 1. Contact information: Surgeon name: Surgeon specialty: Location of practice (city, state): Key contact/practice manager name: Phone number: E-mail address: Question Title * 2. Name of private insurance company: Question Title * 3. Type of health plan: Health Maintenance Organization (HMO) Participating Provider Option (PPO) Point-of-Service (POS) Health Savings Account (HSA) Fee-for-Service (FFS) Other (please specify) Question Title * 4. Do you have a provider agreement with this insurer? Yes No Question Title * 5. What type of issue are you experiencing with this insurer? Please select all that apply. Lack of coverage Prior authorization Surprise billing Network adequacy Narrow networks Tiering Denied or returned claims Other (please specify) Question Title * 6. Please provide a complete description of this issue. If applicable, please include details about the type of services being performed and the CPT codes reported for such services. Question Title * 7. Is this a recurring issue? Yes No Question Title * 8. If yes, approximately how many times have you experienced this issue? Done
