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Site Map > Health Care Providers > Claim Issues > Reporting a Problem to the Department

Reporting a Problem to the Department

If you would like to report a problem regarding claims payment, please complete an online Provider Complaint form.

For individual complaint disputes you wish to submit, please complete an Individual Provider Complaint Form. For multiple "like" complaint disputes you wish to submit, please complete a Multiple Provider Complaint Form. This will enable the Department to commence a substantive review, which may identify system patterns or problems with particular health plans or capitated providers.

Before reporting a problem with a health plan, you should verify that the Department regulates the plan. To view a list of the plans regulated by the Department of Managed Health Care, go to HMO Reports.

All Provider Complaint Form submissions will be tracked for trends and emerging patterns of demonstrable and unjust payment patterns. Before the Department can commence a review, the provider is required to submit the dispute to the payor's Dispute Resolution Mechanism for a minimum of 60 calendar days or until receipt of the payor's written determination, whichever period is shorter.

Please complete this form in as much detail as possible to report your concern with a health care service plan (health plan) or one of the health plan's capitated providers who pay claims.

Appropriate supporting documentation is a prerequisite for a review of any issue. Upon submission of your complaint, an acknowledgement of the Department's receipt of your complaint will be e-mailed to you along with a complaint number, a list of the required supporting documentation and instructions for submitting the documentation.

The Department may forward any information submitted with a provider complaint form to the payor for a response.

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