Escalation Form for HUSKY Providers in Connecticut
The Reach for Escalation Form helps providers contact the HUSKY Member Engagement Services Escalation Unit. This form facilitates communication to obtain necessary support for patients. Use this form to ensure your patients receive timely assistance and resources.
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How do I fill this out?
To fill out the Reach for Escalation Form, gather all necessary details about the member and their needs. Ensure that you have accurate information to facilitate a smooth submission process. Follow the prompts on the form carefully to provide the required information.
How to fill out the Escalation Form for HUSKY Providers in Connecticut?
1
Collect the member's personal details including name and date of birth.
2
Provide the member’s contact information and preferred communication method.
3
Identify the specific assistance needed related to healthcare services.
4
Complete any additional sections as required based on the services needed.
5
Submit the completed form via email or fax as instructed.
Who needs the Escalation Form for HUSKY Providers in Connecticut?
1
Healthcare providers needing assistance locating specialists.
2
Members of HUSKY looking for community resources and support.
3
Patients facing interruptions in their healthcare coverage.
4
Providers responding to urgent patient needs requiring immediate action.
5
Organizations seeking to assist consumers with healthcare-related services.
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What are the instructions for submitting this form?
To submit the Reach for Escalation Form, complete all required fields including member details and specific assistance needed. Once filled, the form can be submitted following these methods: via email to Reachforescalation@chnct.org or by faxing to 203.265.3197. Ensure to keep a copy for your records and to follow up if needed.
What are the important dates for this form in 2024 and 2025?
Key dates for using the Escalation Form include ongoing updates based on HUSKY service changes in 2024 and 2025. Ensure timely submissions align with enrollment periods and eligibility verifications.
What is the purpose of this form?
The purpose of the Reach for Escalation Form is to facilitate efficient communication between providers and the HUSKY member services. This form allows healthcare providers to request necessary support for their patients and address any barriers to care. By utilizing this form, providers can help ensure continuity of care for their patients amidst complex healthcare needs.
Tell me about this form and its components and fields line-by-line.
- 1. Today's Date: The date when the form is filled out.
- 2. Provider NPI: The National Provider Identifier of the submitting provider.
- 3. Provider Office Contact Name: The name of the contact person at the provider's office.
- 4. Member Name: The full name of the HUSKY member requesting assistance.
- 5. Member Date of Birth: The birth date of the member in MM/DD/YYYY format.
- 6. Best way to reach the member: The preferred method of communication to contact the member.
- 7. Member email: The email address of the member, if known.
- 8. Updates via: The means through which the member would like to receive updates.
- 9. Provider Office Phone: The phone number to reach the provider's office.
- 10. HUSKY Member ID: The unique identifier for the HUSKY member.
- 11. Member Current Address: The current address of the member including street, town, and zip code.
- 12. Best phone number to reach the member: The member's best contact phone number.
- 13. Contact member directly: Whether the provider wants the services to contact the member directly.
- 14. Assistance requested: The reasons for which assistance is being sought.
- 15. Provider type needed: The specialties of providers needed for the member.
- 16. By what date: The deadline by which assistance is required.
- 17. Member's diagnosis: Any known diagnoses related to the member's needs.
- 18. Services needed: Specific services, procedures, or treatments requested for the member.
- 19. Care prevented: Details on what healthcare is being hindered.
- 20. DME items needed: Durable Medical Equipment items for the member.
- 21. Transportation needs: If transportation is needed for medical appointments.
- 22. Troubles faced by member: The challenges the member is currently experiencing.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in obtaining necessary healthcare services for members. This could hinder access to required specialists or interim care solutions. It is important to ensure the form is completed accurately and submitted promptly to avoid such issues.
- Delay in Care: Patients may experience delayed care if submissions are not made timely.
- Access Issues: Not submitting can prevent access to crucial healthcare providers.
- Resource Limitations: Clients might miss out on essential community resources.
How do I know when to use this form?
- 1. Finding a Specialist: When a member needs help in locating a specific medical specialist.
- 2. PCP Assistance: When assistance is required to find a Primary Care Physician.
- 3. Insurance Issues: When HUSKY eligibility or insurance questions arise and hinder care.
Frequently Asked Questions
How do I begin filling out the form?
Start by gathering the required member details and access the PDF document on PrintFriendly.
Can I submit this form electronically?
Yes, you can fill out and submit the form via email using the provided email address.
What should I do if I encounter issues?
If you have questions, reach out to the HUSKY Member Engagement Services for assistance.
Is there a limit to the number of members I can submit for?
There is no explicit limit, but ensure each submission is complete and accurate.
How quickly will I receive assistance after submitting?
Typically, responses are prompt; however, it may vary based on the request's complexity.
Can I share this PDF with others?
Yes, you can easily share the completed PDF via email or other platforms.
What if I need to edit the form before submission?
You can freely edit the PDF using PrintFriendly's editing tools before sending it out.
Are updates to member information necessary?
Yes, always provide the most accurate and current information for effective assistance.
Is there any cost associated with this service?
No, using the escalation form and obtaining assistance is free of charge.
How can I ensure my submission is complete?
Double-check all fields for accuracy and completeness before submission.
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