Get Community-rated 10

This guide provides clear and detailed instructions on how to fill out the Community-rated 10 form online. Whether you are a seasoned user or new to digital document management, this step-by-step guide aims to simplify the process for you.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. Begin by filling in the complete identification details for the suspected health care provider(s) or FEHB enrollee(s). This includes their full names, business names, addresses, telephone numbers, dates of birth, social security numbers, enrollee/member numbers, tax identification numbers, and universal provider identification numbers.
3. Provide a brief written explanation of the general allegation regarding suspected fraud, waste, and/or abuse.
4. Indicate how the case was identified, such as through internal sources like customer service or medical review staff, or through external sources like complaints or anonymous tips.
5. Include the total FEHB Program billed and paid amount for a four-year time period, summarizing the exposure without detailing individual claims.
6. Select the appropriate fraud type indicator, including examples like billing for services not rendered, identity theft, or medically unnecessary services.
7. Identify the provider type, which may include categories such as ambulance, hospital, pharmacy, etc.
8. Specify if the provider is an in-network or non-network provider.
9. If applicable, provide employer information for FEHB members or dependent(s), and attach a copy of their SF-2809 Health Benefit Election Form.
10. Include the contact information for the carrier personnel responsible for this notification.
11. After completing all required fields, save your changes, and choose to download, print, or share the completed form.

Complete your documents online to ensure timely submission and accuracy.