Where to send a complaint
Complaints go to different agencies depending on your coverage and the problem. Find your situation below to see who handles it, how to reach them, and what to have ready.
A complaint is not an appeal
If a claim or service was denied, file your appeal by the deadline on your notice, even if you also complain. A complaint usually does not pause or replace an appeal. If care is urgent, ask your plan for an urgent (expedited) appeal first.
Step 1: Know what kind of coverage you have
Who oversees your plan decides where many complaints go. Check your insurance card and plan documents.
| Your coverage | Who usually oversees it |
|---|---|
| A job-based plan where your employer pays claims itself (self-funded) | U.S. Department of Labor |
| A job-based plan bought from an insurance company (fully insured) | Your state insurance department, plus the Department of Labor for federal plan rules |
| A plan you bought yourself, including from the Marketplace | Your state insurance department. The Marketplace handles enrollment and subsidy problems. |
| Medicare, including Medicare Advantage and drug plans | Medicare |
| Medicaid or CHIP | Your state Medicaid agency |
| A job plan from a state or local government, or a church | Rules differ. Ask the plan which agency oversees it. |
Not sure which one you have?
- Ask your HR or benefits office: "Is our plan self-funded or fully insured?"
- Call the member number on your card and ask: "Which agency regulates my plan?"
- Look in your plan booklet (the Summary Plan Description) for a section on your rights.
Step 2: Find your situation
A surprise out-of-network bill, or a provider did not give you a good faith estimate
Who handles it
The federal No Surprises Help Desk. It checks whether surprise-billing rules were followed and can send your complaint to the right federal or state agency.
How to reach them
Call 1-800-985-3059 or submit online. Help is available in English, Spanish, and over 350 other languages.
Official site: Centers for Medicare & Medicaid Services
Have ready
- The bill
- A photo of your insurance card, if you used insurance
- Your EOB, good faith estimate, or any notice and consent form you signed
- Letters with the provider or plan
Write down your confirmation number. If the help desk needs more information, it says it will contact you within 60 days.
Learn more
You paid without insurance and the bill is $400 or more above your good faith estimate
Who handles it
The federal patient-provider dispute process. An independent reviewer decides what you should pay.
How to reach them
Start online through CMS, or by mail or fax, within 120 days of your first bill. There is a $25 fee.
Official site: Centers for Medicare & Medicaid Services
Have ready
- Your written good faith estimate and the provider's contact information
- The bill
- Copies only, not originals
Disputing cannot raise your bill. While it is open, the provider cannot send the bill to collections or charge late fees. If you used insurance, this process does not apply.
Learn more
A job-based plan mishandled your claim, appeal, plan documents, or COBRA
Who handles it
The U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Its benefits advisors help people in private employer plans.
How to reach them
Call 1-866-444-3272, or ask a benefits advisor online.
Official site: U.S. Department of Labor, Employee Benefits Security Administration
Have ready
- Your denial notice and any letters
- Your plan booklet, if you have it
- Dates and names from your calls
EBSA covers private employer plans. Plans from state or local governments and most churches follow other rules.
Learn more
An insurance company treated you unfairly (a plan you bought yourself, or a fully insured job plan)
Who handles it
Your state insurance department. It oversees insurance companies licensed in your state.
How to reach them
Search for your state's insurance department. Many take complaints online. For Marketplace enrollment or subsidy problems, contact HealthCare.gov or your state's Marketplace.
Have ready
- Your insurance card
- Letters, EOBs, and denial notices
- Dates and names from your calls
If your job plan is self-funded, the state usually cannot act on it. Use the Department of Labor instead.
In California
Most HMOs and many PPOs, including Blue Cross and Blue Shield of California, answer to the Department of Managed Health Care (DMHC): file a grievance with your plan first and give it 30 days, unless your health is in serious danger, then call 1-888-466-2219. Other insurance policies go to the Department of Insurance (1-800-927-4357). Self-funded job plans go to neither.
Official site: California Department of Managed Health Care
Official site: California Department of Insurance
Learn more
A problem with Medicare, a Medicare Advantage plan, or a drug plan
Who handles it
For a plan problem, file a complaint (called a grievance) with the plan first. Medicare also takes complaints.
How to reach them
Call 1-800-MEDICARE (1-800-633-4227). Free one-on-one help is available from your State Health Insurance Assistance Program (SHIP).
Official site: Centers for Medicare & Medicaid Services
Have ready
- Your Medicare or plan card
- Letters and notices
- Dates and names from your calls
To challenge a denied service or payment, use the appeal steps on your notice. That is separate from a complaint.
Learn more
A problem with Medicaid or CHIP
Who handles it
Your state Medicaid agency. If you are in a Medicaid health plan, you can also file a grievance with that plan.
How to reach them
Use the phone number on your Medicaid card or notice, or find your state's agency through Medicaid.gov.
Official site: Centers for Medicare & Medicaid Services
Have ready
- Your Medicaid card or case number
- The notice you got
- Dates and names from your calls
If a service was denied or your coverage is ending, ask for a fair hearing by the deadline on your notice. A hearing protects your rights in a way a complaint does not.
Learn more
A hospital will not consider you for financial assistance
Who handles it
The hospital first. Nonprofit hospitals must have a written financial assistance policy and tell patients about it.
How to reach them
Ask the billing office in writing for the policy and an application. Ask them to pause collection while they review it. A free local advocate can help.
Official site: Internal Revenue Service
Have ready
- Your bill
- Proof of income, if you have it
- Notes of who you spoke with
If you think the hospital broke a state law, your state attorney general or health department may take complaints. This varies by state.
In California
The Department of Health Care Access and Information (HCAI) takes complaints when a hospital wrongly denied financial assistance or did not follow the rules on notices or sending debt to collections. It does not handle general billing disputes or good faith estimates.
Official site: California Department of Health Care Access and Information
Learn more
A debt collector, or a credit report error about a medical bill
Who handles it
The Consumer Financial Protection Bureau (CFPB). It sends complaints to the company and tracks the response.
How to reach them
Submit a complaint online with the CFPB.
Official site: Consumer Financial Protection Bureau
Have ready
- Collection letters
- Your bill and EOB
- Any letter you sent disputing the debt
Also dispute the debt in writing with the collector, and dispute report errors with the credit bureau.
Learn more
Agencies can look into whether rules were followed. They cannot promise a refund or a particular result. This guide is general and has not yet been reviewed by an expert.
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
Who can help, and what each one does
Prefer personal support? An independent patient advocate may help. Learn about Navigator & request beta access (Navigator is in development.)
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.
Sources
- Submit a complaint (No Surprises Help Desk)
- Dispute a medical bill (patient-provider dispute resolution)
- Ask EBSA
- Internal appeals
- Medicare.gov
- Medicaid.gov
- Financial assistance policies (FAPs)
- What should I know about debt collection and credit reporting if my medical bill was sent to collections?
- How to File a Complaint
- Health Care Providers Guide To The Complaint Process
- Hospital Bill Complaint Program