Health Care Provider Complaint Form
Revised June 2009
If you are a consumer and wish to file a complaint, please use our Consumer Complaint Form.
If you are a Health Care Provider and would like the Department of Insurance to investigate a complaint against an insurance company or HMO, you may file a complaint either electronically or in hard copy format. Do not file your complaint using your patient’s name as the name of the complainant. Doing so may constitute fraud and may be subject to criminal or civil action.
Note: While the Department encourages provider complaints as an avenue to assist health care providers and consumers and as a method to track market conduct of insurers and HMOs, complaints submitted by collection agencies who have bought the claims are not accepted.
For proper handling of the complaint, you must:
- Submit one Health Care Provider Complaint Form for each patient’s claim.
- Provide a copy of the patient’s insurance identification card.
- For a Prompt Pay complaint, provide proof of date of submission of the claim.
- Provide documentation of your efforts to resolve the problem, including copies of all written correspondence between you and the company AND phone notes of all phone conversations between you and the company;
NOTE: The release of individually identifiable health information may require written authorization from the patient.
For more detailed information, please review Understanding the Provider Complaint Process.
To proceed with filing a provider complaint, please make your selection below.