You can obtain TDI's physician/provider complaint form from:
The TDI Web site . You can either print out the form and mail, fax or submit it online. For online submissions, you must mail or fax to TDI supporting documents, along with a print-out of the submitted form.
Submit documentation for complaints to:
Mail: Texas Department of Insurance, PO Box 149091, Austin TX 78714-9091
The complaint should include:
- Your complete name, address, and phone number;
- The complete name, address, and phone number of the plan;
- The specific type of licensed health plan (insurance, indemnity, HMO, PPO, etc.);
- A concise description of the problem with supporting documents (see below);
- The date you filed the claim;
- The name and address of the patient, insured, or enrollee; and
- The insured's or enrollee's group or policy number.
Refer to the patient's insurance card information when filling out the complaint form. Include the following supporting documents when filing a complaint with TDI regarding a delay in claim payment:
- A copy of the patient´s health insurance identification card;
- A copy of the CMS 1500 or UB-04 claim form submitted to the company for each patient and date of service;
- Evidence of claim submission in the form of:
- Electronic transmission confirmation,
- Certified mail return receipt, or
- Courier delivery confirmation; and
- Evidence of your collection activities for each claim prior to contacting TDI. That evidence should be in the form of:
- Documentation of phone conversations made to the health carrier,
- Copies of correspondence mailed to the health carrier, and
- Replies you have received from the health carrier.
Be sure to separate claims by the HMO or insurance carrier name. Claims for one HMO or insurance carrier must be grouped together and alphabetized by the patient's last name. If there is more than one CMS 1500 or UB-04 for the same patient, staple the forms together. For more information, go to "Provider Resources" on the TDI Web site.
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