Complaint for Health Insurance Claim Denial

Use this form if your health plan has refused to pay for a service, is refusing to pay for future treatment, has paid less than you think they should have paid for your treatment/service, or has canceled your policy.

When filling out this form, use the Next/Previous buttons to move between screens. After you have filled out all screens, use the blue "Proceed" button to submit your completed complaint.

This form will time out after 30 minutes of nonuse. If this happens, you will be logged out and lose your complaint. Please make sure you allow yourself adequate time to complete and submit the complaint form.

Add HEAU Complaint - Health Insurance Appeal

Steps

Patient Information

a10377627281682900
Name Prefix	Name Prefix
First Name*
Middle Name
Last Name*
Name Suffix	Name Suffix
Preferred Pronoun	Pronouns
Other Pronoun
Date Of Birth*
Address Line 1*
Address Line 2 (if necessary)
Zip*
City*
State*	Us State
County*	County
Daytime Phone #*
Alternate Phone #
Fax #
Email Address*
How did you hear about our office?	Complaint Howhearoffice
Other
Is the patient the same person as the filer?*

Complaint - Filer Information

a10377627285980200
Name Prefix	Name Prefix
First Name*
Middle Name
Last Name*
Name Suffix	Name Suffix
Preferred Pronoun	Pronouns
Other Pronoun
Date Of Birth*
Address Line 1*
Address Line 2 (if necessary)
Zip*
City*
State*	Us State
Daytime Phone #*
Alternate Phone #
Fax #
Email Address*

Insurance Carrier

Please complete the following information about the health insurance covering the patient.

Click "+" to add Additional Insurance Carriers

Name of Insurance Carrier*
Carrier Address
Carrier Address Line 2 (if necessary)
Carrier Zip Code
Carrier City
Carrier State	Us State
Carrier Phone #
Carrier Fax #
Carrier Email Address
Carrier Web Address

Click "+" to add Additional Insurance Carriers

Insurance Information

a10377627291267800
Is this your Primary Insurance?
Policy holder first and last name
Group Name or Number (refer to your insurance card)
Membership Number (refer to your insurance card)
Employer Name
Cf Employer Name
Does this complaint concern a Marketplace/Exchange policy?

Insurance Information

Information About Healthcare Provider or Business

Please complete the following information that is the subject of this complaint.

Click "+" to add Additional Health Care Providers or Businesses

Name of Doctor or Business*
Contact Person
Business Address
Business Address Line 2 (if necessary)
Business Zip Code
Business City
Business State	Us State
Business Phone #
Business Fax #
Business Email Address
Business Web Address

Click "+" to add Additional Health Care Providers or Businesses

Complaint Details

Has the patient received the service or care?*

Have you received an Adverse Coverage Decision (EOB/Letter)?

Have you appealed the Carrier's decision?

Have you received an appeal decision?

Tell us about your problem*

Does the complaint involve a delay in medical treatment that could result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, or the member remaining seriously mentally ill with symptoms that cause the member to be a danger to self or others?*

What would you like the carrier or business to do to resolve your complaint?*

Other Information Regarding Your Complaint

Have you filed a complaint with any other governmental agency(s)?

Have you contacted an attorney or filed a lawsuit in this matter?

After reviewing your submission, we may determine that we are not the appropriate agency to handle your complaint. If this occurs we will forward your complaint to the appropriate agency and notify you in writing.

Do you authorize the HEAU to release your complaint information to another agency?*

Important Information

After you select the Proceed button, you will not be able to change any of your information. Please scroll back through the form now to verify your information.

Instructions for forwarding the Authorization for the Release of Medical Information to the Health Education and Advocacy Unit and documentation supporting your complaint.

Please remember that it is important for us to have copies of all relevant documents to properly handle your complaint. Please send or upload copies (do not send originals) of the following documents to the Health Education and Advocacy Unit:

1. A copy of any bills, records or correspondence that relate to your complaint.
2. Authorization for the Release of Medical Information.

In the course of handling your complaint, it is often necessary for our office to obtain medical or insurance claim records and to discuss your medical information with providers, your insurance plan, and other state agencies. You must authorize us to obtain your medical records, including mental health or substance abuse records, and/or insurance information related to the complaint and to discuss the information with other relevant parties. Please download and hand-sign the Authorization for the Release of Medical Information so that we may obtain the information necessary to handle your complaint. Unless the patient is a minor, or someone else has medical power of attorney, the patient must hand-sign the Authorization form.

Depending upon the nature of your complaint, we may not be able to begin our efforts to assist you until your supporting documents and the Authorization for the Release of Medical Information to the Health Education and Advocacy Unit have been received.

You can upload your documents, or mail, email, or fax your documents to:
Office of the Attorney General
Consumer Protection Division
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
heau@oag.maryland.gov
(410) 576-6571 facsimile

Please reference your HEAU case number when mailing, emailing, or faxing any documents.

If you are ready to upload documents with your complaint, select “Attach File” before you select “Proceed” to submit your complaint. If you want to upload documents later, log back into the portal, go to “My Cases,” and select, “Add File.”

Be sure to add your documents to an open case as documents added to a closed case will not be reviewed.

If you have more than one open case, each case will be listed by case number with separate “Add File” buttons so you can select the correct case to add your documents.

Attach Files

IMPORTANT INFORMATION: Not all documents can be uploaded. As you upload each document, look for a check mark (✔) to the left of the file name to confirm it has been accepted. If you upload a document that appears with a red (X) next to the file name, it is not an acceptable file type and must be removed by selecting the "cancel" button. When all (X)-marked files have been removed, you will be able to select Proceed to submit the remaining documents. If you do not remove the red (X) marked files you will not be able to proceed. If you have documents you can't submit through the portal you can email, mail, or fax them to us.

DOCUMENT LIMITATIONS:

Maximum document size is 20 MB.

You may not upload more than 20 documents.

If you have large or numerous documents, we'll provide additional instructions for submitting them when we open your complaint.

You will see an error message - a red (X) - next to the document if it can't be processed. Please "cancel" any errored documents to allow you to submit your complaint ("Proceed"). If you have large or numerous documents, or documents in a file type not accepted, you can email, mail, or fax them to us.

Select File(s)

files

Add files

Consumer Complaints Portal

Add HEAU Complaint - Health Insurance Appeal

Steps

files