Provider Member Complaint

If you would like claims assistance from The Reimbursement Advocacy Firm, please fill out and submit the following form providing brief preliminary information.

*Name of Provider

*Patient's health plan or carrier

Type of Insurance:
Medi-CareHMOPPOVAWorker's CompensationOut of State PlanOther

Is this an employer or group plan (ERISA)?
YESNO

If YES, enter employer name, group name, or group number:

Details of Complaint

Has a the patient considered filing a complaint with the state?
YESNO

If not, will the patient consider filing a complaint?
YESNO

Have YOU filed a complaint with the State?
YESNO

Please check the description that resembles your issue:
Health plan/carrier refuses to reimburse emergency services and care.Health plan/carrier refuses to reimburse statutorily-deemed authorized poststabilization services.Health plan refuses to initiate utilization review.Health plan/carrier has improperly denied a claim.Health plan/carrier has improperly denied prospective or concurrent care.Other

If Other, please explain:

NOTE: Please note that this submission form is not protected by security mechanisms. Therefore, please refrain from including sensitive information and the unsecured tranfer of PHI which could constitute a HIPPA violation.

Provider Contact Information

*Email

*Street Address 1

Street Address 2

*City

*State

*Zip

*Phone

Fax