IN.gov - Skip Navigation
Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.
Please enter your e-mail address to sign up for updates or to access your subscriber preferences.
Please complete the entire form.
Please do not include Social Security Numbers.
Complaint Type: No Pay Late Pay Coding Other:
Complaint is Against: Insurer Third Party Administrator
PLEASE SUPPLY ALL COMPLETE NAMES AS LISTED ON THE INSURANCE CARD.
Claim was filed: On Paper ElectronicallyAmount of claim(s):
Was Claim Clean: Yes No If no, what additional information was requested:
Date of additional information being requested:
Date information was provided:
Partial payment received: Yes Amount Reason given for this amount: No
Dates of attempts to collect payment:
Please include a brief summary of the reason for the complaint, and any additional information you believe will be helpful to the review of your complaint:
More Online Services »