Billing Dispute External Review Administrator

IMEDECS is the independent Billing Dispute External Review Board (BDERB) under settlement agreements between the plaintiff physicians and medical societies and several health plans. Under the settlement agreements, the health plans have established an independent review process for disputes with physicians over application of the companies’ coding and payment methodologies. In association with our strategic partner, Millennium Healthcare, IMEDECS handles appeals from physicians regarding disputes over payment for specific CPT® codes, modifiers, and code combinations.

Members of the class submit petitions directly to IMEDECS after exhausting the plans’ internal appeals process. There are eligibility criteria that providers must meet in order to qualify for the billing dispute external review. The criteria are plan specific but usually include: exhaustion of plan’s internal appeals process; minimum dispute amount; timely filing of petition; and submission of a filing fee.

To initiate most cases, providers must submit the following:

• Completed plan-specific external billing dispute form (available from the health plan)
• Denial letter from final level of internal appeal
• Supporting clinical documentation
• Filing fee

To retrieve forms or for more information on the plan-specific settlements, visit the health plan’s provider information website. For general information about the settlements and the Billing Dispute External Review process, visit the plaintiff’s counsel site at www.hmosettlements.com.