The Department of Financial Services (DFS) reviews alleged prompt pay claim payment violations pursuant to s. 627.6131 and 641.3155, Florida Statutes. A summary of the timelines insurance companies and Health Maintenance Organizations (HMO) are required to meet is available under "Additional Information". Claims not paid or denied by the insurance company or HMO in accordance with Florida regulations should be submitted with written documentation indicating the claims were received by the health plan.
If it is determined that your claims fall within the regulatory authority of the DFS, you will be requested to submit up to five of your outstanding claims for each company. If necessary, we will request additional claims or documentation from you.
Under s. 408.7057, Florida Statutes, claims which 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). The Agency for Health Care Administration (AHCA) contracts with Maximus to administer this dispute resolution program. You may obtain information regarding the claim dispute resolution process by calling Maximus toll free at 1-866-763-6395.
The DFS does not have authority over the following contracts:
Contracts purchased in a state other than Florida. If the contract was purchased in a state other than Florida, you should contact that state’s Department of Insurance. You can access the appropriate state’s contact information on the National Association of Insurance Commissioners’ website at https://content.naic.org/state-insurance-departments.
Self-insured federal government employee contracts.
Self-insured Employee Welfare Benefit Plans established under the Employee Retirement Income Security Act (ERISA).
Prepaid Dental claims (contractual).