1. What is the Statewide Provider and Health Plan Claim Dispute Resolution Program (Dispute Resolution Program)?
The Dispute Resolution Program is a statutorily created program to assist health care providers and health insurance plans resolve health care claims disputes. MAXIMUS is the Agency’s contracted independent dispute resolution organization who serves as the arbitrator of claims disputes between the health care providers and health insurance plans. The program provides a lower cost dispute resolution option to formal litigation.
2. Which regulations govern the Statewide Provider and Health Plan Claim Dispute Resolution Program?
Florida Statute 408.7057 and Florida Administrative Rule 59A-12.030.
3. Who can file a request for claims dispute resolution services under this program?
Providers of health care services that have filed a claim with a health insurance plan including physicians, hospitals, health care institutions (e.g. nursing homes), and other Florida licensed health care providers.
Health insurance plans including HMOs, Prepaid Health Clinics, Prepaid Health Plans, and Exclusive Provider Organizations (EPOs) regulated by the State of Florida.
4. Is health plan or provider participation in the program mandatory?
The program is not mandatory, but provides a path to dispute resolution in lieu of formal litigation. However, once a provider requests arbitration services related to a Statewide Managed Care (SMMC) claim dispute, the SMMC contracted plan must participate in the arbitration process. Once both parties agree to participate, the decision is binding.
5. Are there minimum thresholds that must be met in order to qualify for the program?
Yes, to utilize the Dispute Resolution Program, health care providers must have aggregate claim disputes (for 1 or more patients for same insurer) by type of service that meet minimum thresholds:
|Type of Service||Minimum Thresholds|
|Hospital Inpatient Claims (contracted providers)||$25,000|
|Hospital Inpatient Claims (noncontracted providers)||$10,000|
|Hospital Outpatient Claims (contracted providers)||$10,000|
|Hospital Outpatient Claims (non-contracted providers)||$3,000|
6. How do health care providers and health plans contact the Statewide Provider and Health Plan Claim Dispute Resolution Program (MAXIMUS)?
MAXIMUS can be reached at (866) 763-6395 (select 1 for English or 2 for Spanish), and then select Option 2 and ask for the Florida Provider Appeals Process.
7. What claim disputes are eligible to be heard by the Statewide Provider and Health Plan Claim Dispute Resolution Program?
Claim disputes for services rendered after October 2, 2000 (effective date of the authorizing statute) and claim disputes related to payment amount (amount received or reimbursed amount). Claims must have been denied (in full or in part) or allegedly underpaid or overpaid.
8. What types of claims WILL NOT be heard by the Statewide Provider and Health Plan Claim Dispute Resolution Program?
9. Who handles complaints for late payment of claims?
Complaints for late claim payments regarding commercial managed care plans should be addressed to the Florida Department of Financial Services. The Florida Department of Financial Service can be reached at (800) 342-2762.
Complaints for late claim payment regarding Medicaid managed care plans should be addressed to the Agency for Health Care Administration, Division of Medicaid. A Medicaid representative can be reached at (877) 254-1055 or a complaint can be filed on line at https://ahca.myflorida.com/Medicaid/index.shtml.
10. When filing a claim dispute with the Statewide Provider and Health Plan Claim Dispute Resolution Program, do I need to let the affected party know?
The filing party has to submit a copy of all documentation to the adversely affected party at the same time as submitting to the resolution organization pursuant to 59A-12.030, F.A.C.
11. How long is the review process with Statewide Provider and Health Plan Claim Dispute Resolution Program (MAXIMUS)?
The resolution organization (MAXIMUS) has 60 days to make a recommendation to the Agency after receipt of the appropriate forms and documentation. MAXIMUS has the right to request additional documentation from both parties. The total review time shall not exceed 90 days following receipt of the initial claim dispute request.
12. How long does it take for a final order to be issued?
The Agency has 30 days to issue a final order based upon the date of receipt of the recommendation made by the resolution organization.
13. Is the final order subject to judicial review?
The final order is subject to judicial review pursuant to s. 120.68, F.S.
14. How much does it cost to utilize the claims dispute resolution services?
The resolution organization and the Agency have agreed by contract to the following fee schedule:
Initial review fee to determine eligibility - $75.00/hr.
Physician Expert Review - $215.00/hr.
Utilization Review Nurse - $95.00/hr.
Medical Claim Coding Expert - $125.00/hr.
Legal Expert - $175.00/hr.
Since each claim dispute is different and of varying complexity, the resolution organization will not be able to estimate the full cost in advance; however, the filing party will be provided a review cost estimate in advance, if requested, at no additional charge beyond the initial review fee.
15. Who should pay for witnesses?
Each party must pay for their own witnesses.
16. Can either party request an evidentiary hearing?
Either party may request that the resolution organization conduct an evidentiary hearing in which both sides can present evidence and examine witnesses.
17. When can an evidentiary hearing be requested?
An evidentiary hearing may be requested at any point following the determination that a claim dispute is eligible for arbitration.
18. Is there a cost associated with an evidentiary hearing?
The costs associated with the evidentiary hearing are determined by MAXIMUS upon receiving a request to file a hearing.
19. How will the evidentiary hearing be held?
The evidentiary hearing will be managed by telephonic hearing process. The resolution organization will utilize a Hearing Coordinator to manage the telephonic hearing process.
20. Can either party make an offer to settle the claim dispute prior to the issuance of the final order?
Yes, either party may make an offer to settle the claim dispute at any time during the claim dispute process.