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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

May

16

2019-20 NMA Physician's Leadership Academy Now Accepting Applications

May

03

NMA Resolution Focuses on Destigmatization of Addiction and Substance Use Disorders

Apr

05

Wallet Hub Ranks Nebraska 8th Best Place to Practice Medicine; 1st in Cost of Malpractice Insurance

Mar

29

NMA Providing Support to Members Affected by Flooding

View All Events

Sep

06

2019 Nebraska Medical Association Annual Membership Meeting

News + Events

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