Radiation Oncology Benefit Manager Health Plan Comment Form- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Type of Comment:

Type of Comment (indicate if new or recurrent as applicable):

Type of Comment:

Complaint
Specific Problem
Suggestion

General Information:

Please Provide the Following Information (*Required):

FullName:

MemberNumber:

OfficeAddress:

City:

State:

ZipCode:

OfficeNumber:

Fax:

Email:

Contact:

Patient’s Health Plan Text:

Name of Patient’s Health Plan

HealthPlan:

NameROBMText:

Name of Radiation Oncology Benefit Manager

ROBM:

TreatmentModalityText:

Treatment Modality in question

Treatment Modality:

TypeofProblem:

Type of Problem

Problem Type:

ProblemTypeOther:

IssueDiscription:

Please provide a brief description of your issue/experience with preauthorization procedures

Description of Issue:

CPT Codes:

ContactedROBMText:

Have you contacted the ROBM and/or health plan?

ContactedROBM:

YesNo

IfYesText:

If yes, please provide details

ContactYesDetails:

ASTROHelpText:

How may ASTRO be of further assistance?

ASTROFurtherAssistance:

FurtherInfo:

Please contact the Health Policy Department with any further questions at 703-502-1550.

Daily Practice

Prior Authorization Issues Form