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Requestor
Name
Title
First Name
Last Name
Practice Name
Contact email
Email
City
State
Insurance
Insurance Company
*
Anthem BCBS
Aetna
CIGNA
BCBS
Humana
Medicaid
Medicare Advantage
UnitedHealthcare
Other:
Prior Authorization Vendor
*
Evicore (MedSolutions/Carecore)
NIA – National Imaging Associates
AIM – American Imaging Management
HealthHelp
Other:
Procedure Requested
Patient indication
*
Procedure Requested
*
Resting TTE/Echo
Stress echo
SPECT-MPI/Stress Nuclear
CCTA
CMR
Cardiac Catheterization
Cardiac Event Monitor
Cardiac PET
PCI
Other:
Did the requesting provider consult the AUC?
*
Yes
No
Not sure
If so, what was the level of AUC?
*
Appropriate
Maybe appropriate
Rarely appropriate
AUC does not apply
Not sure
What was the given reason for initial PA denial? (select as many as apply)
*
Not consistent with ACC AUC
Not consistent with Payer Guidelines
Test substitution
Duplicate test
Missing information
Other:
After initial denial, what was the result of the peer to peer consultation?
*
Request Approved
Request Denied
Request Denied with Test Substitution
Deferred decision
Request for more information
No peer to peer discussion
Not sure
If test substitution was requested, what test was substituted? (select as many as apply)
*
EKG
Treadmill
Resting TTE/Echo
Stress echo
SPECT-MPI/Stress Nuclear
CCTA
CMR
Cardiac PET
No test substitution
Not sure
Select the type(s) of practice professionals handling this PA request (select as many as apply)
*
Practice administrator/staff
RN/NP/PA
MD/DO
Other:
How many minutes of practice (cv professionals and staff) time were required to complete the PA process?
*
0-5 minutes
6-10 minutes
11-30 minutes
More than 30 minutes
Not sure
Did your patient have to delay and/or reschedule his/her test/procedure due to the PA process?
*
Yes
No
Additional notes
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