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Pennsylvania payer complaint mechanisms



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  • 1. PennsylvaniaVirtually every third-party payer has a formal internal complaint submission mechanism. Physicians maybe able to successfully resolve disputes through the payer’s internal process. However, if you havesubmitted a claim appeal or complaint to the payer and believe it was not handled fairly, your practicemay benefit from an impartial review of your complaint conducted by a state insurance regulatory agency,your state medical association or the AMA. The complaint submission mechanisms offered through theseorganizations can be helpful in resolving payer disputes.Some links on this page will take you to sites other than the AMA Web site. The AMA is not responsible for thecontent of other Web sites.There are four ways you can file a complaint against health insurers that operate in Pennsylvania:1) Contact the Pennsylvania Insurance Department (Department) The Department accepts complaints regarding untimely payment violations from physicians and other health care professionals. Visit the Department’s Web site to file a complaint against an insurer. To file complaints unrelated to prompt payment, physicians and other health care professionals may be able to file a complaint through their consumer complaint process. There are two ways to file a consumer complaint with the Department: 1) Complete and submit an electronic complaint form 2) Submit your completed complaint form to one of the following offices: HARRISBURG PHILADELPHIA Room 1209 Strawberry Square Room 1701 State Office Bldg Harristown State Office Bldg #1 1400 Spring Garden Street Harrisburg, PA 17120 Philadelphia, PA 19130 Phone: (717) 787-2317 Phone: (215) 560-2630 Fax: (717) 787-8585 Fax: (215) 560-2648 PITTSBURGH Room 304 State Office Bldg 300 Liberty Avenue Pittsburgh, PA 15222 Phone: (412) 565-5020 Fax: (412) 565-7648 For more information on the complaint process, visit the Pennsylvania Insurance Department Web site. 2) Contact the Pennsylvania Department of Health - Act 68 Provider Grievance on Behalf of Member The Pennsylvania Department of Health administers a grievance program and ensures that each licensed HMO has an approved process in place to handle provider grievances on behalf of members. In the event the provider chooses to pursue the Act 68 external appeal process, the provider must notify the appropriate plan of their intent to appeal. The plan will then notify the Pennsylvania Department of Health, Bureau of Managed Care of the provider’s external grievance appeal request. The Bureau assigns the appeal to a Certified Review Entity and the review is completed by a licensed physician or psychologist working in the same or similar specialty as the service under review.
  • 2. Pennsylvania Department of Health Bureau of Managed Care 912 Health & Welfare Building, Room 912 7th & Forster Streets Harrisburg, PA 17120 Phone: 1-717-787-5193 Fax: 1-717-705-0947 Web site: Pennsylvania Department of Health3) Contact the Pennsylvania Medical Society 777 E Park Dr Harrisburg, PA 17111-2753 Phone: (717) 558-7750 Fax: (717) 558-7840 E-mail: stat@pamedsoc.org Web site: www.pamedsoc.org4) Contact the AMA Fill out our Health Plan Complaint Form and/or HIPAA Complaint Form located on the AMA Web site.