Complaint Form

A complaint is considered as the following: Any oral or written communication made directly or indirectly to Beam by any members, brokers, admins, or providers who are alleging that Beam has violated a state law or regulation, inappropriately handled any part of the insurance transaction, or any statement received from a customer that they are dissatisfied with the services provided directly by our company.

Submission info

Your Name*

First & last name Beam employee who handled complaint

Your Email*

Date Received*

Date complaint was received

Date Submitted*

Date submitted to this form

Complaint info

Ticket # or Salesforce URL*

Kustomer or Zendesk #

Ticket Platform

Salesforce

Zendesk

Kustomer

Mobile Application

Complaint Subject*

Select

Summary of Complaint*

Overview of complaint details and any questions/follow ups that need to be addressed.

Complainant Type*

Broker

HR Admin

Member

Provider

Partner

Beam Network

Other Network

Complainant Name*

First & last name or Provider name

Complainant Address, City, ZIP*

Name of Member Insured*

Group ID #*

Member's State*

Please use 2 letter code (i.e. "OH" for "Ohio")

Claim #

Appeal*

Is this related to a claim that needs appealed?

Yes

Method of Contact*

Select

Product Affected*

Select

Is this related to a possible HIPAA Breach?*

If yes, please submit the HIPAA Breach form here: https://app.smartsheet.com/b/form/aa1c1d90772c4ee8bce820e6575af6cf

Select or enter value

Resolution

First Action Detail*

Include: 1) What is the main problem of the complaint? 2) Is this a follow up on previous issues/Zendesk tickets? If so, please include those ticket numbers. 3) Any follow up requests from complaintant. 4) Additional important info

Disposition*

What is the status of the complaint?

Select

2nd Resolution Department

Which department needs to be notified to help resolve/add additional information this complaint?

Select

Final Resolution Detail

Please include: 1) Dates of follow up correspondence with complainant 2) Attach files of closed Zendesk tickets or email correspondence 3) Clarifying details about complaint problem and how it was resolved

Date of Final Resolution

File Attachments

Up to 10 files can be uploaded Each file size can be a max of 30 MB

Drag and drop files here or

Send me a copy of my responses

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