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UTAH MEDICAL ASSOCIATION
Complaint/Action Form

If you are having any problems with insurance/managed care companies that impact your practice or your patients, please take the time to complete a Complaint/Action form.  The Third Party Relations Committee of the Utah Medical Association is compiling this information in an effort to resolve issues with insurance companies. Success of this effort depends upon the willingness of the physician and his/her office staff to submit information to the Utah Medical Association (UMA).

There are two ways to submit this information to UMA, depending on if additional documentation is going to be submitted or not.  If you have supporting documentation to submit, download the PDF version of the Complaint Action Form, fill it out and mail or fax it (801-747-3501) along with the supporting documentation to the UMA office for processing. Be sure to remove any patient identifying information from the support documents before submitting them to UMA.

If you have no additional documentation to send, simply fill out the web form below to submit your complaint.

Carrier Name:    

Carrier Address:    

Carrier Phone #:    

Type of Problem (check all that apply):
Appeals Process
Bundling
Claims Filing (eg, routed wrong)
Coding
Computer Generated Denials
Coordination of Benefits
Coverage Issues
Customer Service
Data Entry Error
Delay in Payment
Denial of Claim
Denial of Prior Authorization
Denial of Referral
Down Coding/Recoding of Claims
Excessive Documentation Request
Excessive Telephone Hold Time
Incorrect Membership Information
Incorrect Reimbursement
Lost Claims
"Missing" Claims Information
"Missing" Support Documentation
Offsetting of Overpayments
Provider File (eg, wrong tax ID#)
Telephone Always Busy
Other (specify below in problem description)

Brief Description of Problem:

Physician Name:               Specialty:

Physician Address:

Phone:

Fax:

Email:

Contact Person:

  

Form Provided By:

Utah Medical Association
ATTN: Third Party Relations Committee
310 E. 4500 South, Suite 500
Salt Lake City, UT 84107

Fax: 801.747.3501

Comments or questions regarding the UMA Web site should be directed to Mark Fotheringham, UMA V.P. of Communications; phone (801)747-3500 or email to mark@utahmed.org

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Copyright © 2007 Mark Fotheringham