Provider/Pharmacy Complaints Against Health Plans/PBM’s

• 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 at 855-408-1212 prior to submitting written complaint.

NOTE:  SHIIP cannot file Medicare Advantage and Medicare Part D complaints on behalf of providers.  

• 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.

• 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.