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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 (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:

   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.