Healthcare Provider Clean Claim Complaint Form - Kentucky Department Of Insurance
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1K
D
I
ENTUCKY
EPARTMENT OF
NSURANCE
R
. 07/08
EV
H
C
P
"CLEAN CLAIM" C
F
EALTH
ARE
ROVIDER
OMPLAINT
ORM
Provider Name:
_________________________________________________________________________________
Provider Type (e.g., pharmacist, physician, etc.): ______________________KY license #:_________________
Address:________________________________________City_________________________State:_____Zip:_________
ontact Person Name: ________________________Fax: (
) _____________
Phone: (
) ______________ C
Insurer Name:
___________________________________________________________________________________
Address:________________________________________City_________________________State:_____Zip:_________
ontact Person Name: _______________________Fax: (
) ______________
Phone: (
) _______________ C
Insured Name:
_________________________ Certificate _________ Plan # __________ Policy # ________________
Patient Name:
_________________________ Patient ID No. _________________
D
C
V
U
P
ESCRIPTION OF
LAIM AND
ERIFICATION OF
NTIMELY
AYMENT
Date(s) services rendered: ________________ Amount of original claim: $ _____________
Date claim first sent to Insurer: ______ Sent by: o Mail o Electronic
(Attach copy of original claim (UB-92, HCFA-1500. etc.)
with any attachments sent)
Are you a participating provider with the Insurer? o Yes o No
Has the Insurer acknowledged receipt of the claim? o Yes o No If yes, when ____________
(Attach copy)
Has the Insurer denied receipt of the claim? o Yes o No
(If yes, attach any documented written proof of your transmittal)
Has the Insurer denied the claim in writing? o Yes o No
(If yes, attach copy)
Has the Insurer made any payment? o Yes o No If yes, how much $__________, and when _____________
Has the Insurer requested additional information? o Yes o No If yes, what additional information was provided by
you to the Insured and when was it provided __________________________________________________________
_______________________________________________________________________________________
(Attach copy)
Please mail this completed form and all supporting
On behalf of the provider, I certify that the above
documentation to:
information is correct:
Signature: ___________________________________
Consumer Protection and Education Division
Kentucky Department of Insurance
P.O. Box 517
Title: _____________________ Date: ___________
Frankfort, KY 40602-0517
Please remember, without proper documentation, your complaint cannot be processed!
The use of this form is suggested but not mandatory
Questions: Call 502-564-6034 or 800-595-6053
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