File a Provider Complaint
The Consumer Services Division of the Department of Insurance stands ready to assist you in resolving insurance problems with companies licensed in Indiana. Contracts of insurance are governed by the state in which the contract is sold. Typically for an individual policy you would contact the state of residence of employer/group. Not all companies are licensed in Indiana; complaints should be directed to the Department of Insurance in the state where the company is licensed and the policy sold (i.e. BC/BS of IL - contact Illinois, BC/BS of KY – contact Kentucky). The Department is an administrative agency of State Government and cannot act in the capacity of a court. But we will thoroughly investigate your problem, advise you whether the company has acted according to the terms of the policy and within the confines of law, and if they have not, will take appropriate action. Example of problems to ask our assistance on: non-payment or continuous late payment of claims, down-coding of claims without notice, payment of non-network provider fee instead of usual and customary. Please note: The Indiana Department of Insurance has no jurisdiction over self-funded employer group health plans. Problems with self-insured plans must be addressed by the Federal Department of Labor. The Indiana Department of Insurance has no jurisdiction over Medicare or Medicaid problems. We do not accept these complaints and will return them.
Claims Payment – THE DEPARTMENT CANNOT ACT AS YOUR COLLECTION SERVICE. However, we do expect companies to take prompt action on claim, to fully investigate all pertinent facts concerning the claim, and make all insurance settlement offers in good faith. Before you ask us for assistance, attempt to solve your issues with the insurer. If your effort is not successful and payment on the clean claim is more than 90 days late, we will be glad to assist in resolving the problem. Please note: if the claim involves Worker’s Compensation, direct your complaint to the Worker’s Compensation Board, 402 W. Washington St. Rm. W196, Indianapolis, IN 46204, unless there has been an award.
What We Need From You – In order to efficiently address your concerns, please follow these guidelines.
- The provider or the patient can file a complaint with the Department.
- A separate complaint should be filed for each patient involved; complaints received that deal with more than one patient will be returned to you.
- All requests for assistance must be in writing and should include:
- A cover letter describing the problem and how you think the problem should be resolved.
- Complete name/address of insurance company (i.e. United American Insurance Co.- not just United).
- A copy of the patient’s insurance card.
- Policy information (insured’s name, patient’s name, group/member/policy numbers).
- Information on claims involved (claim number, date of service, date filed with insurance).
What Next – When your complaint is received at the Department it will be assigned a case number and you will receive an acknowledgement letter. You should refer to the case number when contacting the Department about the case. The Department will notify the insurance company of the complaint and ask for their explanation of the problem. Insurers have 20 business days from receiving the complaint to respond. The Department will review the complaint information and the company’s explanation to determine whether the company is justified in their actions or not. We will then suggest the appropriate resolution to the problem and take the administrative action when appropriate. The Department will communicate with you throughout the investigation.
Attn: Consumer Services Divsion
311 W. Washington Street, Suite 300
Indianapolis, IN 46204-2787