Summer 2009

Love Settlement Agreement update: 
New processes establised for adverse determination appeals and disputes

As part of the Love Settlement Agreement, Blue Cross and Blue Shield of Florida (BCBSF) has launched the Adverse Determination (Medical Necessity and Experimental/Investigational) Appeal process. An Adverse Determination appeal is defined as a written request from a provider for reconsideration of a post-service claim denial made by BCBSF in which certain services provided to BCBSF’s members were not covered, either because they were not medically necessary or because they were experimental or investigational in nature. The written request should be submitted using the new comprehensive Provider Appeal Form (see related article, Provider appeal form streamlined).

Additional information on Adverse Determination appeals is available in the Physician Disclosures section of the BCBSF website at www.bcbsfl.com.

Note: The Adverse Determination Appeal process does not apply to federal employees enrolled in the Blue Cross Blue Shield Service Benefit Plan.

Adverse Determination Disputes

BCBSF has also established the Adverse Determination Dispute process. This process is available only to medical doctors and doctors of osteopathy. A prerequisite to participate in the Adverse Determination Dispute process is to complete the Adverse Determination Appeal process.

Physicians must submit a written request for an Adverse Determination dispute within 60 calendar days from the date of the internal Adverse Determination appeal denial decision by BCBSF to the Independent Review Organization (IRO). MES Solutions has been selected to serve as the IRO. Upon receipt of all necessary documentation, the IRO will conduct the review then notify the physician and BCBSF of its binding determination.

Direct all inquiries regarding Adverse Determination Disputes to MES Solutions at (800) 437-8583.