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
Website: www.mesgroup.com

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