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Medical Providers

Effective July 1, 2023, Maximus is no longer contracted with AHCA as the vendor for independent dispute resolution. They will continue to process any disputes that were submitted to them before July 1, 2023. Please note, all new dispute resolution requests will NOT be processed until AHCA has selected a new vendor.

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 con-cmcu@ahca.myflorida.com. The Agency for Health Care Administration (AHCA) does not have an active vendor to administer the Statewide Provider and Health Plan Claim Dispute Resolution Program. However, AHCA is in the process of procuring a new vendor. Any new disputes will NOT be processed until a new vendor has been contracted. Medical providers inquiring about disputes filed prior to July 1, 2023, may call Maximus, the previous vendor at that time, toll free at 1-866-763-6395.

The DFS does not have authority over the following contracts:

  1. 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.

  2. Self-insured federal government employee contracts.

  3. Self-insured Employee Welfare Benefit Plans established under the Employee Retirement Income Security Act (ERISA).

  4. Prepaid Dental claims (contractual).

Additional Information