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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

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.