Maine Parity Complaint Maine Parity Complaint Form Todays Date / Time *DateTimeOrganization/Provider InformationOrganization NameCity/TownPhoneEmail *Who You Are *SelectSubstance Use Licensed AgencyMental Health Licensed AgencyDual Licensed AgencyIndividual Licensed ProviderContact PersonClaim InformationInsurance CarrierAetnaAnthem/Blue Cross Blue ShieldCIGNACommunity Health OptionsHarvard PilgramUnited Behavioral HealthcareOther CarrierTreatment Service Claim Type (Select One)SUD - InpatientSUD - ResidentialSUD - Partial HospitalizationSUD - Intensive OutpatientSUD - MAT Intensive OutpatientSUD - Office Based MATSUD - Methadone ClinicMH - InpatientMH - ResidentialMH - Partial HospitalizationMH- Intensive OutpatientMH - OutpatientTimes Claim SubmittedFirst TimeMultiple TimesNumber of Times SubmittedDenial Code(s)Brief Description of Problem *Additional comments or suggestionsOverall Experience with this Insurer *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5NameSubmit
