Report A Payor

If you believe you are the target of unfair payment practices and negligent denial tactics, we encourage you to raise your voice by reporting your case.

If you are a Healthcare Provider and would like further claims assistance and representation, we encourage you to visit <a href=”” target=”_blank”>The Reimbursement Advocacy Firm</a> and contact us with your needs.

    *Name of Healthcare 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)?

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

    Details of Complaint

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

    If not, will the patient consider filing a complaint?

    Have YOU filed a complaint with the State?

    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


    *Street Address 1

    Street Address 2