Report suspected fraud

If you believe health care fraud has occurred, complete this form and include as much detail as possible. You don't have to provide your contact information unless you have relevant documentation to share.

Fields marked with an asterisk (*) are required.

Describe the fraudulent activity you would like to report

Description (2000 character limit)

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Claim number associated to this activity

Patient name associated to this activity

Member ID associated to this activity

Submitter has documentation they are willing to provide if requested

Name of the individual or facility performing the potential fraudulent activity

Name of individual

Facility or provider office name

Address

City

State

ZIP code

Phone number

Additional names involved

Address

City

State

ZIP code

Phone number

Submitter's name

Name

Address

City

State

ZIP code

Phone number

Report suspected fraud

Describe the fraudulent activity you would like to report

Name of the individual or facility performing the potential fraudulent activity

Submitter's name

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