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Insurance Complaint Form

Insurance Complaint Form

Carrier Information

Name of Carrier

Address

City

State

Zip Code

Carrier Phone #

Is the plan self-funded or self-insured?

Is the claim under a network provider?

Name of Network

Claim Information

Type of Problem

Without disclosing Protected Health Information (PHI), please describe briefly the nature of the claim issue

Do you have documentation of the problem you described above?

Claim No.

Describe the type of documentation you have

Physician Information

Physician Name

Address

City

State

Zip Code

Specialty

Phone

Fax

Email Address

Date

Month

Day

Year

Contact Person

Members Page

News
Events

Jan

14

Latest DUR Newsletter Published; Nebraska Medicaid to Implement Total Daily Dose Limits on Opioids

Jan

09

Legislature Back in Session; Don't Forget to Register for 2019 Advocacy Breakfast!

Jan

08

All NMA Members, Residents and Medical Students Encouraged to Attend NMA Commission on Legislation Meeting

Jan

07

Amy Reynoldson Assumes Executive Vice President Role at NMA

View All Events

Feb

12

2019 Annual Advocacy Breakfast

News + Events

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