Report Fraud

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Report Fraud

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SUR Referral Form

To make a referral to the SUR Unit for suspected fraud, waste, or abuse, or a quality of care issue regarding either a Medicaid provider or a member, please complete the form below as completely and accurately as possible. Providing up to date contact information is important to facilitate processing of this report. Please be assured this matter will be handled in confidentiality. Fields marked with an asterisk (*) are required fields. The submitted form will be submitted securely for handling by the SUR Unit. Referrals for suspected fraud, waste or abuse may also be reported by calling 1-800-372-2022.

1.	Please provide contact information of the person reporting fraud, waste, or abuse (may not be you):

	Name This answer is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. Email This answer is a required field. This answer is not in the correct format. *Phone This answer is a required field. This answer is not valid or in the correct format. Enter a valid value in the format '999-999-9999'.


2.	Please indicate the type of person reporting fraud, waste or abuse (may not be you): This answer is a required field. Title This answer is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. Practice/Organization/Agency Name This answer is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. Medicaid ID This answer is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/].

*Are you reporting fraud, waste, or abuse for someone else?

Yes


4.	*Is this a referral regarding This answer is a required field.

5.	For referrals regarding providers, please provide the following information (if possible):
	Last Name, First Name The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. National Provider Identifier (NPI) The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/].

6.	For referrals regarding members, please provide the following information (if possible):
	Last Name, First Name The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. Medicaid ID (MID) The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/]. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/].


7.	Type of Referral This answer is a required field. Please specify 0 This answer is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/].


8.	*Explanation of problem (please provide as much detail as possible. Detail should include description of problem, dates of service, claim numbers, etc.) This answer is a required field. The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/].