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Memorándum Informativo para Proveedores de Servicios Médicos

Atención: Todos los Proveedores de Servicios Médicos

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 y 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.

De acuerdo con la sección 408.7057 de los Estatutos de la Florida, las reclamaciones relacionadas con una disputa sobre si el pago debería efectuarse o sobre el monto de un pago, deben ser remitidas al Programa de Resolución de Disputas de Reclamaciones de Plan de Salud y Proveedor Estatal (Maximus). La Agencia para la Administración del Cuidado de Salud (AHCA) tiene un contrato con Maximus para administrar este programa de resolución de disputas. Puede obtener información sobre el proceso de resolución de disputas de reclamaciones llamando a Maximus sin cargo al 1-866-763-6395.

El DFS no tiene autoridad sobre los siguientes contratos:

   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:

Oficina de Administración del Personal de los EE.UU.

Programas de Beneficios de Salud para Empleados Federales

1900 E. Street NW, Room 3443

Washington, DC 20415-0001

Telephone #: (202) 606-0727

For military plans:

Administración de Beneficios Gubernamentales de Palmetto

Departamento de Reclamaciones Tricare

PO Box 7031

Camden, SC 29020-7031

Toll Free Number: 1-800-444-5445

Sitio Web: 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.