Report Suspected Health Care Fraud Form

Please complete this form if you believe that health care fraud and/or abuse may have involved you, a family member or a coworker. Any individual, entity or group that is employed by or provides a service on behalf of Highmark (including employees, members, professional providers, employees of a provider, facility, pharmacy or billing company) may be the subject of the complaint.

This form will be forwarded to the Financial Investigations and Provider Review (FIPR) department for review and evaluation. You will receive a response to your complaint unless you chose to remain anonymous.

Note: To ensure your privacy, all information will be sent via a secure connection. Due to the nature of these investigations, every effort will be made to keep information confidential.

Fields marked with an asterisk (*) are required.

First Name

Last Name

Street Address

City

ZIP Code

Email

Telephone Number

Agreement Number or Provider Number

Do you wish to remain anonymous?

Yes

No

COMPLAINT AGAINST:

First Name

Last Name

Business Name

Street Address

City

ZIP Code

Telephone Number

Agreement Number, Provider Number or Tax ID

Date of Service

Procedure Code Number

Claim Number

Patient Name

Summary of Complaint

Summary of Complaint

Highmark is a registered mark of Highmark Inc. © {currentyear} Highmark Inc., All Rights Reserved.

All references to “Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health benefit administration and/or to one or more of its affiliated Blue companies. This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.

Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal. ®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Wholecare or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company, Highmark Wholecare or Highmark Senior Health Company. PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield or Highmark BCBSD Health Options Inc. d/b/a Highmark Health Options. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company, or Highmark Senior Solutions Company or Highmark Health Options West Virginia Inc. d/b/a Highmark Health Options. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.