Health Care Providers - Complaint Process

Insurance Consumer Hotline: 800-726-7390

Provider Complaint Report Form

Claim filing procedures

The first step to achieving prompt processing of claims is filing claims correctly.

Claim forms must be filled out completely and accurately. Make sure you send the claim to the correct address and if possible, file the claim electronically. Claims will be rejected if they contain incomplete, invalid, or incorrect member identification numbers. If a claim is returned to you because of mistakes, correct them immediately and resubmit to the insurance company to meet any filing deadline specified in your contract or in the patient’s plan document.

Always keep documentation of when the claim was submitted. File the claim using whatever method will best record and document when the claim was received by the insurance company. Keep records of your telephone conversations and all written correspondence between you and the insurance company regarding the status of the claim. Most important, post the claim payment to the account as soon as it is received.

Provider contract disputes

A provider contract with an insurance company is a legal agreement entered into between two private parties. DIFP does not become involved in provider contract disputes or negotiations. We suggest you check the terms of the contract for dispute remedies.

However, if the contract dispute involves balance billing, assignment, recoupments or the prompt payment of claims, we may be able to assist.

What types of provider complaints does DIFP handle?

Many providers seek assistance from us when health claims are delayed, denied or unsatisfactorily settled by insurance companies and HMOs.We can assist providers with these problems - but only to the extent of our authority under the law.

Before filing a complaint

• Contact the insurance company, HMO or administrator about your problem. Document your phone calls by noting the name of the person you speak to, date of call and a brief summary of the conversation.Keep copies of all written communications.

If you are not satisfied with the results you receive, file a provider complaint with us.

Utilization review, grievance and appeals and external review

Utilization review is the process managed care insurance companies and health plans use to review health care services provided to their enrollees or policyholders. These reviews can include prior authorizations, coordination of types and levels of care and whether or not a second opinion is necessary. Often, these are referred to as prospective, concurrent or retrospective reviews. These terms distinguish when the review of the health care service is done in relation to the treatment.

Although we have limited jurisdiction over claim denials for medical necessity, we can ensure the insurance company or its delegated utilization review organization handled the review process in accordance with Missouri law.We can assist providers and enrollees in filing their grievance and appeals to the health plan. We can also refer qualified claims to an independent review organization for an “external” and independent expert medical review of claims. 

If you have problems obtaining a decision from an insurance company or if you believe the review or appeal was not handled appropriately, please contact us or have your patient contact us.  Learn more from our external review process page.

DIFP jurisdiction

DIFP has jurisdiction over “fully insured” health plans. Effective March 1, 2010, all fully insured health plans must clearly print on the front of health insurance identification cards, “Fully Insured.” Fully insured (as opposed to self-insured) plans are subject to Missouri insurance laws and DIFP jurisdiction. This disclosure will assist consumers and health care providers in easily identifying whether the plan is subject to the autism mandate and Missouri law in general. This requirement is pursuant to regulation 20 CSR 100-1.070 “Identification Cards Issued by Health Carriers.”

DIFP does NOT have jurisdiction over these plans:

• Self-insured employers and health and welfare benefit plans – Many large employers provide health benefits for their employees through self-insured plans. Although self-insured plans are frequently administered by an insurance company, it is the employer and not the insurance company that bears the risk for paying claims. State laws, including the prompt pay law, do not apply to self-insured employers and health and welfare benefit plans. Your patients should follow the complaints and appeals procedures contained in their benefit booklets. Many times, these plans have deadlines for filing complaints and appeals that the patient must meet.The U.S. Department of Labor has some oversight of these plans.
• Federal employees plans.
• Medicare HMOs.
• Military insurance.
• Policies purchased in another state.
• Medicare.
• MO HealthNet (Medicaid).
• Missouri Health Insurance Pool (MHIP) – operates federal and state high-risk pools.
• Missouri State Employee Health Plans – MCHCP and other state agency plans.
• Workers’ compensation claims.

For information on how to file complaints regarding the above plans, see filing complaints against health plans not regulated by DIFP.

Filing a complaint

Complaints may be submitted by mail and must include a completed provider complaint form. A separate complaint form must be completed for each patient. Do not complete a complaint form using your patient’s name as the complainant’s name. Patients who want to file complaints should use the consumer complaint form.

Please mail or fax your complaint and all attachments to:

Missouri DIFP
Attention:  Division of Consumer Affairs
P.O. Box 690
Jefferson City, MO 65102-0690
Fax: 573-526-4898

Complaints must include:

• One Provider Complaint Report Form for each patient’s claim.
• Copy of patient’s health insurance ID card.
• Name of insured’s employer if coverage is obtained through an employer group plan.
• Type of benefit plan involved such as HMO, PPO or indemnity, if known.
• Date of original claim.
• Date of service.
• Billed amount for the service.
• Description of the service, or preferably, the CPT code involved.
• Documentation of your attempts to resolve the problem prior to contacting the Division of Consumer Affairs, including the following:
• Copies of correspondence mailed to the insurance company.
• Documentation of phone conversations made to the insurance company.
• Copies of responses you have received from the insurance company.
• In addition to the above information, prompt pay complaints must also include evidence of the date of claim submission such as: 
• Electronic transmission confirmation.
• Certified mail return receipt.
• Provider mail log.
• Courier delivery information

What does the complaint review process entail? 

When we receive your complaint, it will be reviewed to determine if all required information has been provided. If so, a copy of the complaint will be sent to the insurance company. Under Missouri law, insurance companies have 20 days to respond to a complaint. When a response is received from the company, we will review it and take one of the following actions:

• If the complaint is resolved, out complaint file will be closed and you will be sent a letter outlining what information we were provided.
• If an insurance law or rule has been violated, the division will direct the company to reprocess any claims in accordance with Missouri law.
• If the company is not abiding by the policy, the division will request corrective action.
• If no violation of Missouri insurance law or rules is found, a letter will be sent to you with an explanation of the finding and notice that the investigation is being closed.

You will receive a written response from us explaining the results of the investigation.

For more information, call the Insurance Consumer Hotline at 800-726-7390.