Medical Provider Informational Memorandum
Attention: All Medical Providers
You will be asked a series of questions on the following screens which will allow us to
assist you in determining the appropriate federal or state regulatory agency to address
your claim payment concerns. If it is determined your claims fall within the regulatory
authority of the Florida Department of Financial Services (DFS), you will be asked to
submit up to five (5) outstanding claims for each company. If necessary, we will request
additional claims from you.
The Department of Financial Services (DFS) reviews alleged prompt pay claim payment violations
pursuant to s. 627.6131
and 641.3155
, Florida Statutes. Claims not paid or denied by the insurance company or HMO in accordance
with Florida regulations should be submitted with written documentation indicating when
the claims were received by the health plan.
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 (Capitol Bridge). The Agency for Health Care Administration
(AHCA) contracts with Capitol Bridge to administer this dispute resolution program. You may
obtain information regarding the claim dispute resolution process by calling Capitol Bridge
toll free at 1-800-889-0549 or email to FLCDR@capitolbridge.com.
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
http://www.naic.org/state_web_map.htm.
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).
If the patient is covered by a Federal Employee Health Benefit Plan (FEHBP), through the
United States military, or under a self-insured ERISA plan, please contact the following
federal agencies for assistance in resolving your dispute:
For federal employees:
U.S. Office of Personnel Management
Federal Employee Health Benefits Programs
1900 E. Street NW, Room 3443
Washington, DC 20415-0001
Telephone #: (202) 606-0727
For military plans:
Palmetto Government Benefits Administration
Tricare Claims Department
PO Box 7031
Camden, SC 29020-7031
Toll Free Number: 1-800-444-5445
Website Address: Tricare
For self-insured non-governmental plans:
U.S. Department of Labor (USDOL)
Employee Benefit Security Administration
1000 S. Pine Island Road, Suite 100
Plantation, FL 33324
Toll Free Helpline: 1-866-444-3272
NOTE: The USDOL requires claim payment complaints to be filed by
the patient/insured or his/her legal representative.