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, chose option 1 then option 2.
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)
2) Self-insured Federal Government employee contracts,
3) Self-insured Employee Welfare Benefit Plan established under the Employee
Retirement Income Security Act (ERISA), click
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