Managed Care Contracting Request

Please fill out the following form to submit your request. All fields are required.

For ASAP/urgent requests, fill out the form and also contact Carrie Buchen and Helen Rodriguez.

For all other requests, please allow up to 10 business days for a response.

Date of Request Date of Request * / MM / DD YYYY
Requestor's name Requestor's name * First Last
Requestor's extension or phone number *
Requestor's department *
Requestor's email address *
Requestor's supervisor Requestor's supervisor * First Last
Supervisor's Email *
Issue category *

Issue category Contract Question Insurance Question FinThrive Access Request (formerly “nThrive”) Reimbursement Query/Issue - INCLUDES CODES Reimbursement and Policy Report - Fill out Pricing Reports spaces below Provider Rep Change/Inquiry Other - Please Specify Below
Payer(s)
Code(s) – Include any applicable CPT, HCPCS, DRG, and Rev Codes
New Code? *

New Code? Yes No

IF YES: Check codes with Coding Department PRIOR to submitting request to verify accuracy and validity of codes
IF NO: Include claim examples
IF YES: Check codes with Coding Department PRIOR to submitting request to verify accuracy and validity of codes
IF NO: Include claim examples

*Note: for Pricing Report requests involving contracts (such as Medicare and Medicaid) that pay by DRG, requestors are required to provide DRG information to the Managed Care Team prior to the review being started. Thank you.

Facility/Non-Facility

Location

Patient Account Number/Invoice Number, etc. *

Issue details *

Path to documentation (Enter N/A if none.) *

Date needed Date needed * / MM / DD YYYY

If you need this earlier than 10 business days, please email Carrie Buchen, Jenny Berg, and Helen Rodriguez directly.

Managed Care Contracting Request

Managed Care Contracting Request

IF YES: Check codes with Coding Department PRIOR to submitting request to verify accuracy and validity of codes IF NO: Include claim examples

IF YES: Check codes with Coding Department PRIOR to submitting request to verify accuracy and validity of codes
IF NO: Include claim examples