Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the MEDIC Complaint Form and open it for filling out.
2. Begin by specifying whether your complaint pertains to Medicare Advantage (Part C) or Prescription Drug Benefit (Part D) issues.
3. Provide your contact information in the designated sections, including your name, phone number, fax number, and email. Make sure all details are accurate for potential follow-up.
4. Indicate if you are submitting the complaint on behalf of a plan, Pharmacy Benefit Manager (PBM), or another representative entity. Fill in all relevant organizational information, including name and address.
5. Answer the questions regarding whether the information supplied in your complaint was obtained from a PBM and if this referral is considered preliminary.
6. Detail your investigative actions if you are a plan sponsor, indicating if additional steps were taken beyond the information given by the PBM.
7. Fill out the section about the subject or suspect of fraud, including their name, Tax ID, and any relevant business information like the NPI.
8. Provide information regarding the beneficiary, including their name, HICN#, member ID#, and other identifying information.
9. Document the specifics of your complaint, responding to all queries about potential Medicare program exposures, any forwarded matters to law enforcement, and the completion of medical record reviews.
10. Include a detailed description of findings or allegations related to fraudulent activity as an attachment. Make sure to cover all requested elements, including individuals involved and documentation.
11. After completing the form, save your changes. You can then download, print, or share the completed form as needed.

Take the next step today by completing your Qlarant Investigations MEDIC Complaint Form online.