Services for Consumers Guidance for Providers COMPLAINTS AGAINST HEALTH PLANS Before filing a complaint: Attempt to resolve your issues with the insurance company. Reach out to the company’s Provider Relations Team relating to recurring issues such as coding errors, delayed payments or denied claims. Document phone calls to the company-name of person you speak to, date of call and brief summary of conversation. Keep copies of all written communications. Be sure to complete all levels of contractual appeals available. Look closely at patient’s insurance card. If the card names the employer, you should check to see if the plan is self-funded. DOI has no regulatory authority over self-funded plans. Call the Consumer Services Division (855-408-1212) prior to submitting written complaint. If you contact us, we can: Discuss your concerns regarding multiple instances of the same issue and help you determine if filing a complaint is an appropriate course of action. Initiate regulatory action as the Department deems appropriate. What we cannot do: Resolve your contract dispute issues. Determine the value of a claim or the amount of money owed to you. Help you facilitate claim payment in the absence of a statutory issue or policy provision. Address issues with plans not subject to the insurance laws of North Carolina. Consult with you if you are represented by an attorney. PROVIDER REQUEST FOR ASSISTANCE FORM Complaint Form Health Plans the NC Department of Insurance does not regulate: Employees Health Plan-SmartNC may be able to assist with a medical necessity appeal. Other issues relating to this plan can be sent to: State Employees Health Plan Attn: Customer Relations Department 4901 Glenwood Ave., Suite 300 Phone: (919) 881-2300 www.shpnc.org Self-Funded Employee Health Benefit Plans (Self-Insured or ERISA Plans) US Department of Labor Employee Benefits Security Administration Atlanta Federal Center 61 Forsyth Street SW, Suite 7B54 Atlanta, GA 30303 Phone: 866-444-EBSA (3272) www.dol.gov/ebsa/aboutebsa Federal Employees' Health Plan US Office of Personnel Management, Employee Review Retirement & Insurance Group PO Box 436 Washington, DC 20044 Phone: 202-606-0777 Medicare Part A Claims and Provider Problems Palmetto GBA-Medicare Part A 800 S. Duke St. PO Box 3824 Durham, NC 27702 Phone: 877-567-9249 Part B Claims & Provider Problems CIGNA-Medicare Part B 4135 Mendenhall Oaks Parkway, Suite 101 Attn: Public Relations High Point, NC 27265 Phone: 336-882-4562 Medicaid Division of Medical Assistance 2501 Mail Service Center Raleigh, NC 27699-2501 Phone: 919-851-8888 or 800-688-6696 (Provider Inquiries) Phone: 919-855-4400 or 800-662-7030 (Medicaid Recipients) Workers Compensation NC Industrial Commission 430 N. Salisbury Street Raleigh, NC 27603-5937 Phone: 919-733-4820 Provider Licensure and Ethics For Physicians NC Medical Board PO Box 20007 Raleigh, NC 27619 Phone: 919-828-1212 Medical Malpractice or Risk Management Issues: Contact your malpractice insurer Legal/Contract Issues: Issues related to contract enforcement, fraud and abuse and other legal issues, contact your own legal counsel.