Billing Hassle Log Form

ACEP Billing Hassle Log

The American College of Emergency Physicians (ACEP) is interested in understanding your problem encounters with payors for emergency services. In late 2005 the CNAC and Reimbursement Committees developed several templated letters to address the most commonly identified reasons for denials. These letters may be found at:  

ACEP will not be able to respond to your complaint on an individual basis, however the information you supply will be critical to ACEP's understanding of payor behavior. Your feedback will provide ACEP with aggregate data that will be employed to focus ACEP's strategies and resources.

Your responses will be forwarded to the appropriate committee(s) within ACEP. Your name and email if provided will be kept confidential and not shared outside of ACEP.



 Payor State:   
 Medicare B (provider)

* For Part B services, A/B MAC Jurisdiction 11 excludes the Counties of Arlington and Fairfax in Virginia along with the City of Alexandria in Virginia. Services for these areas of Virginia will be covered under A/B MAC Jurisdiction 12

 Workers Compensation            
 Other (please provide payor name)             

Nature of Hassle (check all that apply) 


     Denial - E/M (visit code) & Laceration   
     Denial - E/M (visit code) & X-Ray  
     Denial – E/M (visit code) & Emergency Ultrasound    
     Denial – Critical Care & CPR  
Denial for medical necessity (ICD-9 codes)  
Denial for non-covered service  
Denial for no preapproval  
Nature of Hassle  
No response at all  
Refusal to pay for specific services (i.e. EKG, X-ray, Lacerations, LP)    


Other Complaint

Additional Information 


  Name (optional)   
  Email (optional)   


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