Fraud, Waste and Abuse Referral Form

Date of Referral

First name

Last name

Phone Number

Email Address

Relationship with Gold Kidney Health Plan (i.e. employee, member, provider, etc)

Translation Services Needed (If English is not the primary language, list language below)

Type Of Issue

Medicare Advantage Issue (Part C)Prescription Drug Benefit Issue (Part D)Both Part C and Part D Issue

Member Involved

Member Name

Member ID

Member DOB

Member Phone Number

Member Street Address

Provider Involved

Provider Name or Business Name

Provider NPI

Provider TIN

Provider Medicare ID Number

Provider Phone Number

Provider Street Address

Type of Provider/Business

Primary CareDurable Medical EquipmentMedical SupplySpecialistLaboratoryAmbulancePharmacyEastern Medicine ProviderOther

If, Other

Claim Information (if applicable)

Date of Service

Procedure Codes

Claim Number(s)

Description of Findings/Allegations

(Please provide a detailed description of the nature of the fraud issue including the following: description of fraudulent activity; CPT codes involved; description of individuals and/or businesses involved in the alleged illegal activity; dates that the fraud occurred and names and contact information for victims.)

I certify that the information I am submitting is true and correct to the best of my knowledge.

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