NASW-NYS Managed Care Feedback Form

To support our efforts of advocating for social work professionals and the people we serve, the NASW-NYS Managed Care Task Force has developed the following complaint form to collect data from social work providers who are experiencing difficulties with an insurer. Please complete and submit the following information which will be reviewed by the Managed Care Task Force and Chapter staff.

Data collected through the managed care complaint form will be used to identify managed care trends and systemic areas of concern within the managed care arena.

The NASW-NYS Chapter and/or its Managed Care Task Force is unable to intervene in individual provider/ managed care conflicts unless the problem is of a nature that will have implications for social workers or social work practice as a whole.

*optional

*Provider Name Business Location

City    State:

*Phone #    E-mail

Years of postgraduate clinical social work experience:

Are you currently a NASW-NYS Chapter member? Yes   No

Subject of Complaint (Name of Insurer or HMO):

Type of insurance coverage (plan):

Are you a network/panel provider for the identified company? Yes   No

Have you contacted the company regarding this issue or filed a complaint with a state agency?  Yes   No

If yes, please describe the action(s) you have taken (date) and response received.

Nature of Complaint:

Billing/ Prompt Payment

Audit/ Records Request

Customer/Provider Service

Referral Issue

Claims Authorization/ Denial

Treatment Related Issues

Other

Describe the issue and be as specific as possible about the problem.
(Do not include any identifying client information).

Third Party Reimbursement
Please describe the effects that third party reimbursement rates have had on your professional practice by indicating the potential likelihood of taking each of the following actions:

As a result of current 3rd party reimbursement levels, I have or am planning to…

5
Very Likely

4
Likely

3
Uncertain

2
Unlikely

1
Very Unlikely

Stop accepting insurance
as a form of payment.

Disenroll from one or more
provider panels.

Close my private practice.

Reduce my private practice
caseload.

Increase my private practice
caseload.

Seek other forms of income.

Leave the social work
profession entirely.

Reimbursement levels will have
no effect on my practice.

Additional Comments:


May we contact you if we have further questions about this submission? 
Yes   No

  

If you will be submitting supporting documents to the chapter under separate cover please include your contact info and reference your online feedback submission and send to:
NASW-NYS Chapter, 188 Washington Ave, Albany, NY 12210
or Fax: 518-463-6446
ATTN: Managed Care Task Force

Privacy Notice:
NASW-NYS will not share any of your personal identification information with any other entity.  It does reserve the right to share some or all of the other remaining information provided on this form.

 
   
NASW-NYS   188 Washington Ave.   Albany, NY 12210   Tel: 518.463.4741 or 800.724.6279   Fax: 518.463.6446   info@naswnys.org