Medical Provider Informational Memorandum
Attention: All Medical Providers
The Department of Financial Services (DFS)
reviews health claim payment delays pursuant to
Florida Statute Sections 627.6131 and 641.3155.
A summary of the timeline insurance
companies are required to meet is available
through this link:
Processing Claims in a Timely Manner. Claims not paid or denied by the health insurance plan or Health Maintenance Organization (HMO) in accordance with the above Florida laws should be submitted to us with written proof the claims in question have been
received by the insurance plan. Please complete the
Medical Provider Request for Assistance
Form available on this site and include the requested documentation listed on the form, for our review. We realize we are only requesting five (5) of your outstanding claims; however, we believe a sample of five (5) will assist us in determining a routine business practice. If necessary, we will request additional claims from you. Please do not submit personal medical records.
Under Florida Statute 408.7057, claims that
involve a dispute regarding whether payment
should be made, or the amount of a payment,
should be referred to the Statewide Provider and
Health Plan Claim Dispute Resolution Program (Maximus).
Currently, the Agency for Health Care
Administration has contracted with Maximus to
administer this program. You may obtain
information regarding their claim dispute
resolution process by calling 1-866-763-6395.
The DFS does not have authority over the
following contracts:
1)
Contracts purchased in a State other than
Florida,
2)
Self-insured Federal Government employee
contracts,
3)
Self-insured Employee Welfare Benefit Plan
established under the Employee Retirement Income
Security Act (ERISA),
4)
and, Prepaid Dental claims
(contractual)
Additional Information:
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