Health Insurance Complaint | Employer-provided

Complaint | Type of Insurance |  Health | Employer-provided


Out-of-state Employer


The Arizona Department of Insurance only has authority over insurance policies issued to Arizona citizens and businesses.  For employer-provided group insurance, the employer is the policyholder (the business to which the policy was issued).  You, as an employee, are an enrollee of the employer's policy.  If your employer is based outside Arizona, the Arizona Department of Insurance does not have jurisdiction to investigate your complaint.  You should contact the department of insurance in the state where your employer is based.


Health Care Appeals Process


If your insurance company has denied payment or approval for medical/dental/optometric/etc. ("health") services or supplies, your first step is to follow the insurance company's appeal process.  Arizona insurance laws require health insurers, HMOs, dental plans, prepaid dental plans and vision plans authorized by the Arizona Department of Insurance to provide their insured members a process for appealing any denied claim or denied service ("Health Care Appeals Information Packet").  Arizona's health care appeals process is available from our Internet web site at https://insurance.az.gov/consumers/help-problem/filing-health-care-appeal.  You should be able to obtain your insurer's Health Care Appeals Information Packet by calling the member services telephone number on your insurance card.

If you went through the appeal process and the company continued to deny payment or approval, look at your health benefits identification card and see if it contains any of the following wording:

Self-funded plan ID cards often contain one of the following phrases near the insurer's name:  "Administered by," "As administrator for," "Administrative services only," or "ASO."   Arizona state government employees are covered by a self-funded plan.

Group insurance plan ID cards may contain the phrase "Underwritten by," or "Insured by" near the insurer's name.


What Type of Plan Is Your Arizona-based Employer Providing?

Your next step depends upon whether you are covered by a self-funded plan or by a group insurance plan.


 

Warning - Phishing Scam

We are aware of a phishing scam targeting insurance professionals claiming that the National Association of Insurance Commissioners received a complaint that the professional submitted a falsified claim. This fraudulent email displays the NAIC and CIPR logos, can originate from what appears to be an naic.org or gmail.com email account, and instructs the recipient to click on a link to download the complaint notification.

Certain antivirus products will detect this as a malicious email.  If you receive a similar email and have any concerns, contact the NAIC Service Desk at (816) 783-8500 or [email protected].