Carrier Advocacy Request
The society has developed this form for members to submit carrier information when denied reimbursement to the physician or the patient for specific interventional radiology treatments.
To initiate societal “comment letters” please complete the information below.
Member Information
SIR Membership Number
Your SIR membership number can be found in your online member profile at https://www.sirweb.org/myaccount
First Name
Last Name
Email Address
Phone Number
Have you contacted the Carrier ?
Yes
No
Carrier Information
Please provide us with information pertaining to the Carrier.
Identify Carrier
Please explain where you are in the appeal process. Has a peer-to-peer (P2P) or a 2nd level appeal already been done?
Carrier Contact Person
Address Line 1
(Suite, Unit, Floor, Room, etc.)
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip
Phone Number
Denial Reason
Please attach a copy of the denial letter.
*Please ensure all patient information is redacted from any denial document you submit.
If you have any questions, please contact the
economics team
.