GLMS Hassle Report Form
GLMS works diligently to identify problematic insurance related trends and address these hassles with carriers. After first following the appeals process for the carrier, let us know what hassles you are experiencing. Complete the form below to report specific problems/trends or to request assistance in resolving issues. We will compile a summary of these issues in aggregate and discuss problematic patterns with insurers.
Practice or Physician Name: *
Your answer
Your Name: *
Your answer
Phone: *
Your answer
Email: *
Your answer
Briefly describe the issue: *
Your answer
If you would like assistance with the resolution of this hassle, provide the following information (if available):
Carrier:
Your answer
Plan Type (Bluecard, Exchange Plan, etc.)
Your answer
Provider/Customer Service Reference #:
Your answer
Manager or carrier representative involved in this issue:
Your answer
Claim Number(s):
Your answer
Date(s) of Service:
MM
/
DD
/
YYYY
Questions? Contact Stephanie Woods:
stephanie.woods@glms.org | P: (502) 736-6350 F: (502) 736-6351
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