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Medicare FYI

FRAUD AND ABUSE REFERRAL FORMDate:

 Blue Cross Blue Shield of MN Medicare Part A Anti-Fraud Unit PO Box 64357 St. Paul, MN 55164-0357 (651) 456-8000 Fax: (651) 456-1050

 United Healthcare Ins. Co. Medicare Part B Anti-Fraud Unit 8120 Penn Avenue South Bloomington, MN 55431 (612) 885-2921 Fax: (612) 885-2900

 AdminaStar Federal, Inc. DMEFC Region B Clearinghouse Unit PO Box 6128 Indianapolis, IN 46206 (800) 270-8313 Fax: (317) 841-4600

 United Government Services Beneficiary Services 1515 N Rivercenter Drive Milwaukee, WI 53212-3953 (414) 226-5000 Fax: (414) 226-5226

 Office of the Attorney General Medicaid Fraud Division 445 Minnesota Street St. Paul, MN 55101 (651) 296-7575 Fax: (651) 297-4139

 Other

From (Name of Person Filling Out Form): ______________________________________________________________________________ Organization: __________________________________________________________________ Address: ______________________________________________________________________ City: _______________________________________    State: ____    Zip: _________________ Phone (inc. area code): __________________________    Fax#: _________________________ Email: ______________________________________ Contact me at: ____________________________    between: ________a.m. and ________p.m.

Regarding: (Beneficiary Name): Medicare #: ___________________________    Medicaid #: ____________________________ Address: ______________________________________________________________________ City: _______________________________________    State: ____    Zip: _________________ Phone (inc. area code): __________________________ Ethnicity: _______________________________________________    Gender: _____________ This information is voluntary for internal reporting purposes only. Contact me at: ____________________________    between: ________a.m. and ________p.m. Complaint Against: (Name of facility, Provider, physician, lab, supplier, etc.) ______________________________________________________________________________ Date(s) of Service: ______________________________ Business Name: ______________________________________________________________ Phone (inc. area code): __________________________ Address: ______________________________________________________________________ City: _______________________________________    State: ____    Zip: _________________ What prompted you to make a referral:          Medicare FYI Fraud & Abuse Forum          Health Insurance Counseling Program          Outreach (radio, brochure, TV ad etc.)          Own initiative          Other Describe your complaint. If known, include procedure code and/or description of service, amounts billed, amount you paid, etc. You may continue on the next page, if there is insufficient room on this page. *If service(s) were allegedly not provided, please complete the non-rendered service questionnaire in the following area.

Description of Complaint (continued):

*Non-rendered Services Questionnaire: Did you see anyone else for service that day? _______ If yes, who? (Physician's Assistance, Nurse, Lab/X-ray) Technician, etc: ________________________________________________________________ Was the service(s) done on another day? _______    If yes, on what day? _________________ Did you have any other services that day? _______ If yes, what type of service and where? _____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did you already contact the provider/supplier regarding your complaint? ____ Yes    ____ No If yes, who did you speak to and what did he/she say?

Do you have a copy of the Medicare Benefit Notice and/or bill relating to this incident? ____ Yes    ____ No If yes, please send a copy with this report.

Please attached any information pertaining to this complaint. A completed authorization to release information is necessary to provide information to anyone other than the beneficiary or his/her Representative Payee.

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