Compliance

FWA REFERRAL FORM

This form should be used to report allegations which may be indicative of fraud, waste, and/or abuse involving pharmacies, members, and/or prescribers.

Examples include, but are not limited to:

• Member: doctor shopping, eligibility fraud
• Prescriber: over-prescribing, collusion, kick-backs
• Pharmacy: billing name brand prescriptions and providing generics, intentionally billing a higher priced NDC code than what was dispensed, drug splitting

INSTRUCTIONS: Please provide as much information and detail as possible regarding the allegation. After completing this form, please click "Submit" and the information will be sent securely to Prime for investigation. Any additional information or attachments can be e-mailed to ReportFraud@primetherapeutics.com

If you have questions on how to complete this form or would like to report your allegation verbally, please contact the Fraud, Waste and Abuse Hotline at 800.731.3269.

Date reported
Date activity was identified
Insurance Plan impacted
Carrier/Account/Group
Information of person initiating this report
Name
Company
Department
Title
Phone number
E-mail address
Details regarding questioned activity
Member name
Member ID
Member telephone number
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Pharmacy name
Pharmacy NPI
Pharmacy physical address
---
Prescriber name
Prescriber NPI
Prescriber clinic/hospital name
---
Date(s) of service
Prescription number(s)
Additional details
1. Provide details of the allegation including how the issue was identified.
2. Describe what rule, policy and/or law you suspect is being violated.
3. List the name(s) and contact information for any other individual(s) who may have information about this allegation.
4. Describe what, if any, steps you have taken to resolve this issue and what the outcome was.

Thank you for taking the time to report this information to Prime Therapeutics. Should we need any additional information pertaining to this investigation, you will be contacted.