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.
- 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.