Billing Dispute External Review Process



The Billing Dispute External Review Process (BDERP) will provide for a Billing Dispute External Reviewer
(BDER), to resolve disputes with physicians and physician groups arising from covered services provided
to BCBSF’s members by such physicians and/or physician groups concerning:

• For Coding and Payment Rule appeals finally adjudicated on or after August 21, 2008, BCBSF’s
application of BCBSF’s coding and payment rules and methodologies for covered fee for service
claims (including any bundling, downcoding, application of a CPT modifier, and/or other reassignment
of a code by BCBSF) to patient specific factual situations, including without limitation the appropriate
payment when two or more CPT codes are billed together, or whether a payment enhancing modifier
is appropriate. All such Billing Disputes must be submitted to the BDER no more than 90 calendar
days after a physician or physician group exhausts the internal appeal process, except the parties
have agreed that for appeals finally adjudicated after August 21, 2008 and before November 21,
2008, the date the BDERP will start accepting claims, the physicians and physician groups will have
until December 20, 2008 to submit their eligible billing disputes. For calculation purposes, the start
date will be the date on the appeal letter and the ending date will be when a Billing Dispute is
received by the BDER. This will determine if the 90 calendar day requirement is met; or

• The BDER will not have jurisdiction over any other disputes, including disputes that fall within the
scope of the Independent Review process within the Love (formerly Thomas) Settlement Agreement,
Compliance Disputes and disputes concerning the scope of covered services. Also, the BDER will not
have jurisdiction or authority to revise or establish any BCBSF reimbursement policy.
Other requirements:

• A physician or physician group must submit all documentation reasonably needed to decide the
internal appeal to BCBSF’s Provider Appeal and Dispute Department. A physician or physician group
will be deemed to have exhausted BCBSF’s internal appeal process, if BCBSF does not
communicate a decision on an internal appeal within 30 calendar days of BCBSF’s Provider Disputes
Department receipt of all documentation reasonably needed to decide the internal appeal.

• The amount in dispute by the physician or physician group must exceed $500.00. A physician or
physician group may submit multiple Billing Disputes with an amount in dispute less than $500.00; if
the physician or physician group notifies the BDER that the physician or physician group intends to
submit additional Billing Disputes during the one (1) year period following the submission of the
original Billing Dispute, which involves issues that are similar to those of the original Billing Dispute.

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

• The BDER process is not available to a physician or physician group when the member has a Federal
Employee Health Benefit Agreement.

• BCBSF’s contract with the organization selected to serve as a BDER will require 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).

• In the event that the BDER issues a decision requiring payment by BCBSF, BCBSF will make the
payment within 15 calendar days after receiving the decision notice.

Contact MES Solutions for all Billing Dispute External Review process inquiries:

MES Solutions
Attn: BDRP Dept
100 Morse St
Norwood, MA 02062
Phone: (800) 437-8583
Fax: (888) 869-2087
Website: www.mesgroup.com

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