Get Qlarant Investigations Medic Complaint Form

The Qlarant Investigations MEDIC Complaint Form is designed to facilitate the reporting of fraud, waste, and abuse in Medicare Parts C and D programs. This guide will provide you with clear, step-by-step instructions to help ensure your complaint is completed accurately and effectively.

Follow the steps to fill out the Qlarant Investigations MEDIC Complaint Form online

1. Click ‘Get Form’ button to access the Qlarant Investigations MEDIC Complaint Form online and open it for editing.
2. Begin by designating whether your complaint pertains to a Medicare Advantage issue (Part C), a prescription drug benefit issue (Part D), or both. Select the appropriate option.
3. Provide the date of referral to document when the complaint is being filed.
4. Enter your contact information in the Complainant Contact Information section. Include your name, fax number, phone number, and email address. Choose the submission method from the options provided (Plan, PBM, UPIC, or Other) and fill in any applicable details.
5. Input the complainant organization name, city, address, state, and zip code, as well as the Plan Name/Contract # and Plan Tracking # if applicable.
6. If you are representing a parent organization or a pharmacy benefit manager, provide that information in the relevant fields.
7. Complete the Beneficiary Information section by entering the beneficiary's name, phone number, HICN#, MBI#, address, city, date of birth, primary language (if not English), and state. Indicate the Medicare plan name and check whether the beneficiary is a subject of investigation.
8. Reply to the questions regarding contact reports on the beneficiary, selecting the appropriate response.
9. In the Description of Subject/Suspect of Fraud section, enter the details for one subject or suspect at a time, including their NPI, Tax ID, name, Medicare provider number, DEA number, phone number, business name, state, city, address, and zip code.
10. Briefly describe the type of business or physician specialty involved in the complaint.
11. In the Complaint Details section, input the potential Medicare program exposure amount and any applicable prior MEDIC case number. Complete the section indicating whether this matter was forwarded to law enforcement, if medical records were received, and whether a medical record review was completed.
12. Provide a comprehensive description of findings and allegations related to the complaint. Attach any related documentation that supports your claims, including letters and advertising.
13. After completing the form, review all entries for accuracy. Save your changes, and choose to download, print, or share the completed form as needed.

Complete your complaint form online today to report any instances of fraud, waste, or abuse.