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KENTUCKY DEPARTMENT OF INSURANCE HEALTH CARE PROVIDER CLEAN CLAIM” COMPLAINT FORM REV. 07/08 Provider Name: Provider Type (e.g., pharmacist, physician, etc.): KY license #: Address: City State:

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What is clean claim complaint form?

Clean claim complaint form is a form used to report any issues or disputes regarding a claim that has been submitted to an insurance company for payment.

Who is required to file clean claim complaint form?

Any healthcare provider or facility that has submitted a claim for payment to an insurance company may be required to file a clean claim complaint form.

How to fill out clean claim complaint form?

To fill out a clean claim complaint form, you will need to provide details about the claim, the issue or dispute, and any supporting documentation. The form may be submitted online, by mail, or by fax.

What is the purpose of clean claim complaint form?

The purpose of clean claim complaint form is to address and resolve any issues or disputes related to a submitted claim, ensuring timely and accurate payment.

What information must be reported on clean claim complaint form?

Information such as the claim number, patient information, service dates, reason for dispute, and any supporting documentation must be reported on the clean claim complaint form.

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