OSI Events Calendar View our calendar of events Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 5The New Mexico Office of Superintendent of Insurance investigates health care provider complaints filed against health care insurers such as health maintenance organizations, individual health plans, group and blanket plans, provider service networks, non-profit healthcare plans and third-party payers or their agents that provide, offer or administer health benefit plans subject to the insurance laws and regulations of this state. The Superintendent can assist with grievances regarding provider termination, discrimination, credentialing, timely payment of claims and other provider concerns in regards to the operations of the health insurer or plan.Provider Information Date *Name *TitleNPIPractice/Group Name (If Applicable) *Email *Phone *Address *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAuthorized Contact NamePhoneEmailNextInsurance Company Information you Address Name *Contracted *YesNoAddress Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeType of PlanHMOPPOEPOPOSOtherPreviousNextComplaint Type (Please check all that apply)* Complaint Type *Credentialing DeadlinesClaim payment amount or timingClaim submission requirements or complianceNetwork adequacy, including participation determinations based on network composition qualificationsNetwork composition including providerUtilization management practicesProvider contract construction or compliancePatient care standards or access to careSurprise billing reimbursement amount, rate or timingTerminationOperation of the planDiscriminationDoes this grievance pertain to Medicaid or Medicare coverage, excluding Medicare supplement? *YesNoHave you already contacted the Insurance Company with this issue? *YesNoIs this complaint related to any previously submitted complaints? *YesNoPreviousNextPlease describe your complaint, the attempts you have made to resolve the complaint, and the outcome you are requesting: (Attach additional pages, if necessary) *Copies of any correspondence between you and the Company, Uniform Bill, Claims Spreadsheet (with at least patient name, claim number and date of service) and Customer Authorization Form (if applicable), are required. Drag & Drop Files, Choose Files to Upload You can upload up to 10 files. PreviousNextBatch Complaints Section Divider Insurance Company Information Name *Contracted *YesNoAddress Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeType of PlanIndividualGroupHMOPPOEPOPOSOther Claim Information A CLAIMS SPREADSHEET WITH AT LEAST PATIENT NAME, CLAIM NUMBER AND DATE OF SERVICE CAN BE SUBMITTED (UPLOADED) ON PREVIOUS PAGE (STEP 4) IN LIEU OF FILLING CLAIMS INFORMATION ONLINE. Patient NameEmployer Name Group #Policy ID NumberClaim NumberDate of ServiceDate of Claim Submitted Add more claims Remove PreviousSubmit
