Benefits Verification Error Report Form
Report and document errors encountered during the benefits verification process to ensure timely resolution.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Organization or Department
Are you reporting this error on behalf of someone else?
*
Yes
No
Name of Member/Patient Affected
*
First Name
Last Name
Member/Patient ID (last 4 digits only)
Type of Benefit Involved
*
Please Select
Medical
Dental
Vision
Pharmacy
Other
Date Error Was Discovered
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe the error encountered during benefits verification
*
What impact did this error have?
Have any steps already been taken to resolve this issue? If yes, please describe.
Upload any supporting documentation (screenshots, error messages, correspondence, etc.)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Resolution or Next Steps Requested
Submit Error Report
Should be Empty: