BCBSF - Physician Disclosures

This page contains information from Blue Cross and Blue Shield of Florida (BCBSF) and Health Options, Inc. pertaining to the Love (formerly Thomas) Settlement. The following links provide information for the first set of requirements.

Provider Appeal Process

BCBSF/Health Options currently has three types of appeal processes – Physician Coding and Payment Rule Appeal, Adverse Determination Appeal, and Provider Utilization Management Claim Appeal Process.

Physician Coding and Payment Rule Appeal

A Physician Coding and Payment Rule Appeal is a written request from a licensed health care practitioner for reconsideration of a health care claim based on BCBSF's/HealthOptions' application of its coding and payment rules and methodologies (including without limitation any bundling, downcoding, application of a CPT modifier, and/or other reassignment of a code by BCBSF).

Click here for more information about Physician Coding and Payment Rule Appeals.
Click here for the Provider Appeal Form.

Billing Dispute

In compliance with the Love (formerly Thomas) Settlement Agreement, Blue Cross and Blue Shield of Florida, Inc., (BCBSF) has established the Billing Dispute Review process. This process became effective August 21, 2008. The Billing Dispute External Reviewer, MES Solutions, will begin accepting and processing claim disputes as of November 21, 2008. A pre-requisite to participate in this process is to complete the Physician Coding and Payment Rule Appeal process.

Billing Disputes must be submitted to the Billing Dispute Reviewer no more than 90 calendar days after a Physician or Physician Group exhausts the Physician Coding and Payment Rule Appeal process, except those eligible billing disputes arising after August 21, 2008 and before the Billing Dispute External Reviewer will accept Billing Disputes on November 21, 2008. These later Billing Disputes must be submitted to the Billing Dispute External Reviewer no later that December 20, 2008.

Click here for the Billing Dispute Form.
Click here to submit Billing Dispute Resolution requests.

Provider Adverse Determination Appeal

A written request from a provider for reconsideration of a post-service claim denial made by BCBSF that certain services provided to BCBSF's Members by Providers are not Covered Services because they are not Medically Necessary or Experimental or Investigational in nature.

Provider Adverse Determination Disputes

In compliance with the Love (formerly Thomas) Settlement Agreement, Blue Cross and Blue Shield of Florida, Inc., (BCBSF) has established the Adverse Determination Dispute process. This process became effective April 21, 2009. The Independent Review Organization (IRO), MES Solutions, will begin accepting and processing Adverse Determination Dispute disputes as of April 21, 2009. A pre-requisite to participate in this process is to complete the Provider Adverse Determination Appeal process.

Adverse Determination Disputes must be submitted to the IRO no more than 60 calendar days after a Physician or Physician Group exhausts the Provider Adverse Determination Appeal process.

Provider Utilization Management Appeal

This Provider Utilization Management (UM) Appeal form is for use by physicians and providers who bill on a CMS-1500 or UB-04 form. The appeal must relate to an authorization or precertification problem that affected payment.

Definition of Medically Necessary or Medical Necessity

BCBSF/Health Options has defined Medically Necessary or Medical Necessity health care services in accordance with generally accepted standards of medical practice; clinical appropriateness in terms of type, frequency, extent, site and duration; and effectiveness for the patient's illness, injury or disease. BCBSF/Health Options provides a full definition of Medically Necessary or Medical Necessity covering services and sequence of services.

Click here for the full definition of Medically Necessary or Medical Necessity.

Limited Categories Requiring the Routine Submission of Clinical Information by Medical Doctors and Doctors of Osteopathy

BCBSF/Health Options may require Clinical Information before and after payment of a claim. This Clinical Information is required to process claims, for example, where there was a pre-existing condition, issues pertaining to mental health, psychiatric and substance abuse, organ transplants, cosmetic and reconstructive surgery, and/or a number of other limited categories.

Click here for a complete list of Limited Categories Requiring the Routine Submission of Clinical Information by Medical Doctors and Doctors of Osteopathy.

Claim Processes and Procedures

Claim Filing Process

BCBSF/Health Options provides a variety of helpful information to assist you in your claims filing process.

Click here for more information on claims processes and procedures.
Click here for the Provider Claim Inquiry Form.

Claim Submission Process

Submit claims for both the Electronic and Paper based claim submissions to BCBSF/Health Options.

Click here for more information about the Electronic and Paper Claim Submission Appeals.

Overpayment Recovery Procedures

Our policy is to diligently pursue the timely recovery of all identified medical expense overpayments using a payment offsetting method. An overpayment is reimbursement in excess of the monetary obligation that BCBSF/Health Options has with respect to a particular claim.

Authorization to Release Mental Health Clinical Information Form

This form allows BCBSF/Health Options to obtain authorization for the release of Clinical Information from patients through their Provider. Click here for the Authorization to Release Mental Health Clinical Information Form.

Significant Edits

Significant Edits are those edits that, based upon BCBSF Health Options claim experience, would result in denied or reduction in payment for a particular coding combination more than 250 times per year. BCBSF/Health Options posts the Significant Edits Listing once a year. The Significant Edits Listing is located on the Availity website. In order to view the information, an Availity login ID and password are required. Login IDs are available using the registration process through the link below.

Physician Advisory Committee

Blue Cross Blue Shield of Florida/Health Options, Inc., (BCBSF/HOI) has established a Physician Advisory Committee (PAC) made up of 12 member physicians (each a participating physician) that provide healthcare guidance and recommendations.

The BCBSF/HOI PAC will discuss issues arising from or related to the relationships and interactions between and among Physicians, their patients, and BCBSF/HOI. These issues may include, but are not limited to: (a) improvement of health care and clinical quality; (b) improvement of communications, relations and cooperation between Physicians and BCBSF/HOI; and/or (c) matters of a clinical or administrative nature that impact the interaction between Physicians and BCBSF/HOI.

The BCBSF/HOI PAC will meet at least once every six months. All communications to the BCBSF/HOI PAC by participating and/or non-participating Physicians will occur through members of the Physician Advisory Committee who will represent the interests the participating and/or non-participating Physicians.

Standard Authorization and Admission Certification

Blue Cross and Blue Shield of Florida, Inc. maintains a standard list of conditions that routinely require an authorization or admission certification by BCBSF/HOI for services and/or supplies that are Medically Necessary and/or not experimental or investigational. This list is subject to change without notice. Please refer back to this website to check the standard authorizations and admission certifications list, as updates will be posted in a timely manner.

Click here to view the standard authorizations and admission certifications lists.

Non-Standard Authorization and Admission Certification

The following is a non-standard list of conditions that require an authorization or admission certification by BCBSF/HOI for services and/or supplies that are Medically Necessary and/or not experimental or investigational. This list is subject to change without notice. Please refer back to this website to check the standard authorizations and admission certifications list, as updates will be posted in a timely manner.

Click here to view the non-standard authorizations and admission certifications lists.

Limited Code Combinations

The following is a list of limited code combinations that have been determined to have particular services or procedures, relative to modifiers 25 & 59, that are not appropriately reported together with those modifiers and BCBSF's application differs from CPT^® Codes.

Customized Edits

The following is a list of customized claim check edits that were applied to BCBSF's claim editing software.

Physician Disclosures - BCBSF