Provider Fraud Inquiry

For the quickest, most accurate response, please fill in as much information as possible. We will respond to you by e-mail. (* denotes required fields). Please allow up to 5 business days for a response.

*Your First Name:
*Your Last Name:
*Your Phone Number:  ext
 
* Your Email Address:

Your Address

Address:
City:
State:
ZIP:
*Response Method:

Subscriber and Patient Information

Federal Employee:
*Prefix/ID Number: -

The patient's Blue Cross and Blue Shield of Nebraska identification number (including the prefix) is located on the front of their ID card.
 

*Subscriber First Name:
*Subscriber Last Name:


Person Complaint is About

*First Name:
*Last Name:
Address:
City:
State:
ZIP:
Phone Number:  ext 
Incident Date:
*Summary of Complaint: