Medicare

Autism Provider Resource Center

Claim Filing Procedures

The first step to achieving prompt processing of claims is filing claims correctly. Claim forms must be filled out completely and accurately. Make sure you send the claim to the correct address and if possible, file the claim electronically. Claims will be rejected if they contain incomplete, invalid, or incorrect member identification numbers. If a claim is returned to you because of mistakes, correct them immediately and resubmit to the insurance company to meet any filing deadline specified in your contract or in the patient’s plan document.

Always keep documentation of when the claim was submitted. File the claim using whatever method will best record and document when the claim was received by the insurance company. Keep records of your telephone conversations and all written correspondence between you and the insurance company regarding the status of the claim. Most importantly, post the claim payment to the account as soon as it is received.

Credentialing Procedures

The first step to achieving credentialing status is to fill out the health carrier's credentialing form completely and accurately, including if the health carrier encourages or requires electronic credentialing applications. Make sure you send the application to the correct address. Do not send your credentialing application to Mississippi Insurance Department! Make sure you keep a copy of your application form, and record the date that you sent it to the health carrier.

Provider Contract Disputes

A provider contract with an insurance company is a legal agreement entered into between two private parties. The Mississippi Insurance Department (“MID”) does not become involved in provider contract disputes or negotiations. We suggest you check the terms of the contract for dispute remedies.

However, if the contract dispute involves balance billing, assignment, recoupments or the prompt payment of claims, we may be able to assist.

What types of provider complaints does MID handle?

Many providers seek assistance from us when health claims are delayed, denied or unsatisfactorily settled by insurance companies and HMOs. We can assist providers with these problems - but only to the extent of our authority under the law.

Before filing a complaint

  • Contact the insurance company, HMO or administrator about your problem. Document your phone calls by noting the name of the person you speak to, date of call and a brief summary of the conversation. Keep copies of all written communications.

If you are not satisfied with the results you receive, file a complaint with MID.

Utilization review, grievance and appeals and external review

Utilization review is the process managed care insurance companies and health plans use to review health care services provided to their enrollees or policyholders. These reviews can include prior authorizations, coordination of types and levels of care and whether or not a second opinion is necessary. Often, these are referred to as prospective, concurrent or retrospective reviews. These terms distinguish when the review of the health care service is done in relation to the treatment.

Although we have limited jurisdiction over claim denials for medical necessity, we can ensure the insurance company or its delegated utilization review organization handled the review process in accordance with Mississippi law. We can assist providers and enrollees in filing their grievance and appeals to the health plan. MID can also refer qualified claims to an independent review organization for an “external” and independent expert medical review of claims.

If you have problems obtaining a decision from an insurance company or if you believe the review or appeal was not handled appropriately, please contact us or have your patient contact us. Learn more from our external review process page.

MID Jurisdiction

MID has jurisdiction over “fully insured” health plans. Fully insured (as opposed to self-insured) plans are subject to all Mississippi insurance laws enforced by the Department.

MID does NOT have jurisdiction over these plans:

  • Self-insured employers and health and welfare benefit plans – Many large employers provide health benefits for their employees through self-insured plans. Although self-insured plans are frequently administered by an insurance company, it is the employer and not the insurance company that bears the risk for paying claims. State laws, including the prompt pay law, do not apply to self-insured employers and health and welfare benefit plans. Your patients should follow the complaints and appeals procedures contained in their benefit booklets. Many times, these plans have deadlines for filing complaints and appeals that the patient must meet. The U.S. Department of Labor has some oversight of these plans.
  • Federal employees plans.
  • Medicare HMOs.
  • Military insurance.
  • Policies purchased in another state.
  • Medicare.
  • Medicaid and Medicaid managed care plans
  • Mississippi State and School Employees’ Life and Health Insurance Plan.
  • Workers’ compensation claims.

Filing a Complaint

To file a complaint against a company, please refer to the Mississippi Insurance Department Consumer Division or call the Autism Hotline at 1-833-488-6472.

To file an Electronic complaint against a company, you may use the Electronic (Online) Consumer Complaint Form below. By doing so, we will receive immediate notification of your complaint and it will be assigned to one of our Consumer Services Specialist.

Online Consumer Complaint Form

You may download and print (Adobe Acrobat Reader required) the complaint form below. Fax or mail the completed form to the fax number or address below:

Company Complaint Form (Fillable PDF)

Mississippi Insurance Department
Attn: Consumer Services Division
P.O. Box 79
Jackson, MS 39205
Fax Number: 601-359-1077
Email: consumer@mid.ms.gov

***To request a form by mail you may call: (800) 562-2957 or (601) 359-2453 or send written request to the above mailing address.***

The following information MUST be included in order for the Mississippi Insurance Department to be able to properly process your complaint:

  • Your name and your relationship to the insured.
  • Daytime telephone number
  • Name of insured.
  • Insured's address name, address, city, zip code, and phone number.
  • The name of the insurance company with which the insured is having a problem.
  • Address of the insurance company with which the insured is having a problem.
  • Type of insurance, policy number, claim number, and date of loss.
  • Description of complaint
  • Form is signed and dated.

What happens when we receive your complaint:

Once we receive your complaint, it will be assigned to one of our Consumer Services Specialist, who will review it and take the necessary steps to resolve the matter.