For Providers

Resolve an Issue or File a Complaint

Health care providers should review their health plan contracts and administrative policies on appeals before filing a complaint. Providers should also contact the relevant insurance companies and attempt to resolve the issue through discussion and negotiation before contacting OHIC.

For additional assistance, please visit OHIC's customer assistance partner: RI Reach or call toll-free at 1-(855)-747-3224

The Office of the Health Insurance Commissioner’s (OHIC) regulation 230-RICR-20-30-6 - “Prompt Processing of Claims” requires insurance companies to process complete electronic claims submitted by Rhode Island health care providers and policyholders within thirty calendar days from receipt of said complete claim and to process complete written claims submitted by Rhode Island health care providers and policyholders within forty calendar days from receipt of said clean claims.

To begin the process, please refer to ‘Exhibit C’, of OHIC’s “Prompt Processing Complaint Form” located on page 10.

1. A provider must first file a written complaint with the subject entity (the insurer) before filing a written complaint with the OHIC. To file a complaint with the subject entity: (1) complete the complaint form, (2) attach copies of the claims (do not send original documents) in question, (3) include a detailed written description of the complaint on the form and (4) if the complaint involves multiple claims, please use the spreadsheet form found on page three of the Exhibit.

• Pleast note: The complaint should be sent to the subject entity by certified or registered mail, with a return receipt requested, or by any other method of delivery that provides written proof of delivery.

2. If after 45 days of completing the ‘Complaint Form’ and sending to the insurer this matter is not resolved, you may file this complaint with OHIC according to the instructions located in paragraph 3 of the Exhibit

Please note: OHIC maintains jurisdiction over fully insured commercial health plans only. This does not include Medicare (including dual Integrity), Medicare Advantage or Medicaid plans (i.e. NHP/United products such as Rhody and/or Rite Care).