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Program integrity referral form

If you, in good faith, have a suspicion that a TRICARE provider or a beneficiary have committed an act of fraud or abuse, you may report this suspicion to Humana Military Program Integrity. All allegations of fraud and abuse are investigated to determine whether there is sufficient evidence to report the case to the government for further investigation.

Please complete as many of the following fields as you have knowledge.

* Denotes Required fields

Referral details

Is the subject a beneficiary or a provider? Beneficiary Provider

Name of subject to be investigated:

Address 1 of subject:

Address 2 of subject:

City:

State:

Zip:

Telephone of subject:

Ext:

Allegation information

Detailed allegation (Please be as specific as possible, including dates, names, etc.):

How did you become aware of this allegation?

Contact information

Contact information so Humana Military Program Integrity may contact you to follow-up on this allegation:

Must provide at least your name and phone number:

Your name:

Address 1:

Address 2:

City:

State:

Zip:

Telephone:

Ext:

Email Address:

Additional information

Has any correspondence occurred between you and the subject that may be helpful to the investigation?

Yes No

If yes, what does this consist of?

Are you aware of another individual who may be helpful to the investigation?

Yes No

If so, list name and contact information:

Contact name:

Contact Address 1:

Contact Address 2:

City:

State:

Zip:

Telephone:

Ext:

Email Address:

Have questions? Contact us