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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

View All News

Oct

Crowdfunding Campaign: Make a Gift That Has Lasting Impact - Your Donation Will Be Matched!

Oct

Be Safe This Halloween: Medication Can Easily Be Mistaken for Candy

Oct

UHC Community Plan Provider Assistance Meeting

Oct

Brandeis EMBA for Physicians: Scholarships available! Apply Now - Deadline November 1, 2019

View All Events

Nov

Understanding Home Health Care in Nebraska Webinar

Dec

Updates in Colon Cancer Screening

Jan

NMA Annual Advocacy Breakfast

News + Events

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