Report a Payor : ERN Enterprises, Inc.

Name of Healthcare Provider

Patient’s Health Plan or Carrier

Type of Insurance

Is this an employer or group plan (ERISA)?

YES

NO

If “YES,” enter employer name, group name, or group number

DETAILS OF COMPLAINT

Please provide more information about the incident being reported.

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

YES

NO

If not, will the patient consider filing a complaint?

YES

NO

Have YOU filed a complaint with the State?

YES

NO

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:

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

PROVIDER CONTACT INFORMATION

Please provide more information about the healthcare provider who provided services in this incident.

Provider email address

Name of contact from provider

First

Last

Provider mailing address

Provider phone number

Provider fax number

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