Jump to navigation

Jump to content

Jump to contact information

Medical Provider Informational Memorandum

Attention: All Medical Providers

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.

Please be advised:

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 required is included. 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.

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 then chose option 5.

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 will need to contact that State Department of
    Insurance. For your convenience, we have provided the link to the National
    Association of Insurance Commissioner (NAIC) www.naic.org/state_web_map.htm.
2) Self-insured Federal Government employee contracts,
3) Self-insured Employee Welfare Benefit Plan established under the Employee
    Retirement Income Security Act (ERISA), click Here
4) and, Prepaid Dental claims (contractual).

If the patient is covered by a Federal Employee Health Plan or through the United States Military, please contact the following organizations for assistance in resolving your dispute:

For Federal Employees:

U.S. Office of Personnel Management

Federal Employee Health Benefits Programs

Insurance Review Division, #1

1900 E. Street NW

Washington, DC 20415-3500

Telephone #: 1-202-606-0727

For Military Plans:

Palmetto Government Benefits Administration

Tricare Claims Department

PO Box 7031

Camden, SC 29020-7031

Toll Free: 1-800403-3950 South Region or

Website Address: Tricare