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
Website: www.mesgroup.com
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