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ABOUT US
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Access Committee
Advocacy Committee
Education Committee
Quality Committee
Membership Committee
MiBAP ONLINE STORE
MEMBERS
JOIN
NEWS & EVENTS
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EVENTS
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PARITY & ACCESS
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Parity & Access
Parity & Access Hotline Form
Date of Report
(Required)
MM slash DD slash YYYY
Name of Person Reporting
(Required)
First
Last
Your Email Address
(Required)
Your Phone
(Required)
Provider Organization
(Required)
CMH/PIHP
(Required)
CMH/PIHP Contact
(Required)
Type of Service Denied or Limited
(Required)
Direct Therapy
Protocol Modification
Family Guidance
Assessment
Group Therapy
Date of Suspected Violation
(Required)
MM slash DD slash YYYY
Reason Given for Denial
(Required)
Was an appeal filed?
(Required)
Yes
No
Appeal Outcome
(Required)
Impact on Patient Care
(Required)
Parity
Access to Care
Arbitrary Cap on Hours
Payor Dictated Length of Tx
Delay in Treatment
Worsening Condition
Discharge from Service
Pause in Service
Loss of Hours
Loss of Staffing
Other
Number of clients impacted:
(Required)
Individual
Impact of Group
Did the insurance company or school provide a written explanation?
(Required)
Yes
No
Additional Comments
