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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. 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:

 

On the following screens, you will be asked a series of questions that will allow us to assist you in determining the appropriate regulatory entity to address your claim payment concerns. If it is determined that your concerns do fall within the regulatory authority of the Florida Department of Financial Services, you will be asked to submit up to five (5) of your outstanding claims (per company). If necessary, we will request additional claims from you.

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