Sunday, 3 August 2014

Adverse Determination External Review Process

 The Adverse Determination External Review process will provide for an Independent Review Organization (IRO), to resolve disputes with physicians and physician groups arising from BCBSF’s determination that certain services provided to BCBSF’s members are not covered services because they are not medically necessary, experimental or investigational in nature, supportive of an experimental or investigational procedure, or supportive of a not medically necessary procedure (“Adverse Determination Disputes”). The external review process is only available if BCBSF makes the Adverse Determination and administers its Plan Member appeals and/or external review process. Additionally, the Adverse Determination External Review Process is only available if BCBSF upholds its initial Adverse Determination through the internal Post-Service Appeals process and the cost of the service at issue exceeds the threshold amount, if any, the BCBSF’s Plan member would need to satisfy in order to seek external review under the terms of the applicable health benefit plan. 

The physician or physician group may file an Adverse Determination Dispute with the IRO, if BCBSF upholds its initial Adverse Determination through the internal Adverse Determination Appeals process and the following requirements are met:

• Only Medical Doctors, Doctors of Osteopathy, and their physician groups may file an Adverse Determination Dispute. No other provider type (e.g., Doctor of Chiropractic Medicine, Doctor of
Podiatry, etc.) may file an Adverse Determination Dispute.

• A pre-requisite to participate in the Adverse Determination Dispute process is to complete the Adverse Determination Appeals process.

• BCBSF must have issued its denial decision of the Adverse Determination Appeal on or after April 21, 2009.

• To be considered by the IRO, a Physician or Physician Group must submit a written request for external review (i.e., Adverse Determination Dispute) to the IRO within sixty (60) calendar days from the date of the internal Adverse Determination Appeal denial decision by BCBSF with the appropriate fee. BCBSF’s contract with the IRO requires decisions to be rendered not later than 30 calendar days after receipt of the documents necessary for the review and to provide notice of the decisions to BCBSF and physician(s) or physician group(s). The IRO’s external reviewer shall be of the same specialty (but not necessarily the same sub-specialty), as the appealing physician. The physician or physician group may not initiate an Adverse Determination Dispute of any denied service if:

• BCBSF’s member is covered under a Self-Insured Plan and the Plan sponsor has not agreed by contract to participate in the Adverse Determination Dispute process 
• BCBSF’s member is covered by a Federal Employee Health Benefit Agreement. Contact MES Solutions, the IRO for BCBSF, for all Adverse Determination Dispute process inquiries: 
MES Solutions Attn:
 Love Settlement Dept  
100 Morse St Norwood, MA 02062
Phone: (800) 437-8583
Fax: (888) 868-2087

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