Physician Billing and Medical Necessity Disputes

Dispute Resolution Process for Physician Billing Disputes

Medical Doctors (MD physicians) participating in the Love Settlement agreement may qualify for a billing dispute external review (BDER) process after exhaustion of the Blue Cross and Blue Shield of Alabama initial internal appeal process. MES Solutions has been selected as the Billing Dispute Resolution Reviewer as directed by the Love Settlement agreement. This review process seeks to resolve disputes concerning application of coding and payment rules and methodologies for fee for service claims to patient specific factual situations. This includes bundling (fragmented coding), downcoding, application of a Physicians' Current Procedural Terminology (CPT) modifier, and/or other reassignment of a code. An individual Medical Doctor or Medical Doctor group must exhaust the initial internal appeal process and the dispute must exceed $500 to qualify for the external billing dispute process. A filing fee, dependent on the amount in dispute, must also be submitted with the request.

Dispute Resolution Process for Medical Necessity Disputes

This review process seeks to resolve disputes concerning services that are determined to be non-covered due to not being medically necessary or are experimental or investigational in nature. The physician must exhaust the post service internal appeal process to qualify for the external review process. The physician may submit a written request to MES within 60 days from the date of the internal post service appeal non-coverage decision. Physicians seeking external review shall pay a filing fee of $50 if the amount in dispute is $1,000 or less or $250 if the amount in dispute exceeds $1,000. Payment must be submitted with the review request.

Providers can submit a billing or medical necessity dispute resolution to MES Solutions online through their web site or by submitting it to the address or fax number below:

MES Solutions
Attention: BDRP Department
100 Morse Street
Norwood, MA 02062
Fax: 1 888 868-2087
Customer Support: 1 800 437-8583

For further information on the external review process and applicable filing fees, refer to the MES Solutions web site.

Providers may also access the Blue Cross and Blue Shield of Alabama Provider Appeals section on our web site for additional information on these type disputes.