Florida Blue Billing: Timely Filing, Corrected Claims and Appeals

Florida Blue Filing, Prior Authorization and Portal

Appeal Levels

Top Denials from Florida Blue

Where Is the Florida Blue Provider Manual and Which Part Covers Billing?

Florida Blue posts its Manual for Physicians and Providers as three core PDFs on its provider manual page, plus separate files for facility and ancillary provider types. The one that matters for billing is the second, Claim Submission and Billing Guidelines, a 107-page PDF.

Florida Blue states that the manual "is not intended to be a complete statement of all Florida Blue polices or procedures" and that any section may be updated at any time. Your participating agreement and the network manager are the final word. State rules for Florida, including the prompt pay law, are on our Florida billing guide, and the shared Blue Cross Blue Shield rules, including BlueCard, are on the Blue Cross Blue Shield page.

What Is the Florida Blue Timely Filing Limit?

Florida Blue's Claim Submission and Billing Guidelines say all claim submissions have a 180-day timely filing limit. The same manual says providers must file inside the time set in their participating agreement unless applicable law requires a longer period.

The full wording: if applicable to a benefit agreement, current Florida law and other legal requirements provide that claims must be filed within 180 days after the date of service and receipt by the provider of the name and address of the patient's health insurer. A supplemental claim for additional diagnoses must be filed within 180 days of the original evaluation and management service.

A late claim can be appealed as a Timely Filing Appeal, one of the administrative appeal types on the Provider Reconsideration/Administrative Appeal Form. Attach proof of the first submission and the remittance advice.

How Do I Submit Claims and Check Status with Florida Blue?

Submit electronic claims through Availity, either directly or through a billing service or clearinghouse that sends to Availity. Florida Blue's manual says Availity edits claims against HIPAA requirements and payer-specific edits first. A claim that fails is not forwarded to Florida Blue, and the failure shows on your electronic batch report.

• Check status in Availity before you resubmit. The manual asks you to allow 15 days for electronic claims and 30 days for paper claims, and 30 days for Medicare Supplement claims waiting on Medicare, before sending a claim again.
• Send the whole member ID including the prefix. The manual says to use the member ID, not the Social Security number.
• Send claims whether or not you collected the copayment, deductible or coinsurance.
• Paper claims go through optical character recognition. Florida Blue returns claims it cannot scan, and a returned claim is resubmitted as a new claim, not a corrected one.

Facility-based professional claims need the Service Facility Location. Florida Blue says it cannot identify claims tied to an institutional stay, or claims that qualify under the No Surprises Act, without the facility name, address and NPI, and denies a claim when that information is missing or incorrect.

How Do I Send a Corrected or Voided Claim to Florida Blue?

Start a new claim with the full set of information, set the claim frequency code to 7 for a replacement or 8 for a void, and include the original claim number from the remittance advice. Florida Blue's manual says to submit a corrected claim only after the original has finalized and you hold the remittance advice, to avoid a duplicate denial.

• Send the whole claim, not just the changed lines. Do not submit separate claims for omitted services; the manual says that creates a split-billed claim and all of them deny.
• A corrected claim is not an appeal, the manual says. Do not send a corrected claim to add modifier 25 or 59 to a code on the original claim; submit a coding and payment rule appeal with the form and records.
• A paid claim sent in error is refunded with the Claim Overpayment Refund Form rather than voided. The manual gives 30 calendar days from identification to return an overpayment you find.

What Are the Florida Blue Appeal Levels and Deadlines?

Florida Blue gives providers one level of post-service appeal, and the manual says there is no second level. Appeals must be submitted within one year of the date on the remittance advice, and the manual says Florida Blue will not overturn denials based on failure to follow required procedures and time frames.

• Send everything at the time of appeal. The manual says all documentation must be submitted then, and duplicate requests are not processed.
• Asking Florida Blue to reprocess a claim is not an appeal. Reprocessing requests follow the claim submission rules above.
• If an appeal is overturned, the claim goes back for adjustment and reprocessing. If it is upheld, you get a written decision.
• You may not balance bill members for covered services, including disputed amounts.

Complete the Provider Reconsideration/Administrative Appeal Form or the Provider Clinical Appeal Form, attach the remittance advice and records, and mail administrative appeals to Florida Blue, P.O. Box 1798, Jacksonville, FL 32231. Clinical, coding and payment rule appeals go to the Provider Disputes Department, P.O. Box 44232, Jacksonville, FL 32231-4232.

Two limits to know. Some denials are not eligible for provider appeal at all; the manual names office and outpatient evaluation and management codes for place of service 19 or 22 and drug screens. And if a member appeal and a provider appeal reach Florida Blue for the same service, the member appeal goes forward and the provider appeal is dismissed. A provider appealing on the member's behalf needs the Appointment of Representative form, and then it is handled as a member appeal.

How Do I Check Eligibility and Submit Prior Authorization for Florida Blue Members?

Verify coverage in Availity at check-in and confirm whether the service needs prior authorization there or by calling 1-800-727-2227. The manual notes that Florida members enrolled in an individual or small group qualified health plan need prior authorization for advanced imaging, specialty medical pharmacy and sleep studies.

1. At check-in, check eligibility and benefits in Availity, or call 1-800-727-2227, and note the member's product and network.
2. Read the member's guidelines in Availity and the Utilization Management table for that product to see whether the service needs authorization, certification or notification.
3. Request authorization electronically through Availity. For a planned admission do it five business days ahead; for an unplanned one, within one business day.
4. Use the Coverage Guidelines link at the bottom of the Eligibility and Benefits results to read the medical policy before the visit.
5. A service that needs no authorization is still subject to medical necessity review, so keep the visit documentation ready.

For myBlue members, the assigned primary care physician must issue referrals to specialists, and the manual says the referral is not an authorization for all services; the specialist must still get authorization in Availity. Under your agreement you must comply with Florida Blue's medical management programs, including obtaining authorizations, certifications or notifications, giving clinical information on request, and naming a facility contact for the nurse reviewer.

Emergency care is handled differently by product. For BlueMedicare HMO, PPO and Group PPO, the manual says no authorization is required for emergency services in or out of the service area, but BlueMedicare HMO requires an authorization and the PPO products require a notification when the emergency leads to an inpatient admission.

What Authorization and Notification Does Florida Blue Require from Hospitals and EDs?

It depends on the member's product. Part 1 of the manual carries a Utilization Management table by commercial product and network, and the manual tells you to check Availity for the member's specific guidelines. It also says a service that needs no authorization is still subject to medical necessity review before, after or during the stay.

The same table says newborn admissions need their own authorization when the baby stays after the mother is discharged. Participating acute care facilities must also tell Florida Blue about member admissions to skilled nursing facilities before close of business the day after admission.

How Do I Dispute an Out-of-Network Underpayment from Florida Blue?

Florida Blue's billing manual includes a section for claims and services that qualify under the No Surprises Act. It says services rendered on or after January 1, 2022 by non-participating providers may be subject to the NSA rules, and it sets claim data requirements so Florida Blue can identify those claims.

• Professional claims from a hospital or facility need the facility name and NPI: CMS-1500 fields 32, 32a and 32b on paper, and the service facility location in loop 2310C on the 837P.
• Independent clinical lab claims performed for ambulatory surgery centers must use place of service 24.
• Air ambulance must carry revenue code 545 and ground ambulance revenue code 540, on separate claims.

The dispute itself follows federal rules: see open negotiation, how federal IDR works and state surprise billing laws.

Which Denials Come up Most on Florida Blue Claims?

The manual ties denials to missing facility data, missing authorizations and timing. The table lists the CARC that matches each.