Bill Text: FL S1232 | 2010 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Health Insurance [CPSC]

Spectrum: Partisan Bill (Republican 2-0)

Status: (Failed) 2010-04-30 - Died in Committee on Commerce [S1232 Detail]

Download: Florida-2010-S1232-Introduced.html
 
Florida Senate - 2010                                    SB 1232 
 
By Senator Fasano 
11-00578B-10                                          20101232__ 
1                        A bill to be entitled 
2         An act relating to health services claims; amending s. 
3         627.6141, F.S.; authorizing appeals from denials of 
4         certain claims for certain services; requiring a 
5         health insurer to conduct a retrospective review of 
6         the medical necessity of a service under certain 
7         circumstances; requiring the health insurer to submit 
8         a written justification for a determination that a 
9         service was not medically necessary and provide a 
10         process for appealing the determination; amending s. 
11         641.3156, F.S.; authorizing appeals from denials of 
12         certain claims for certain services; requiring a 
13         health maintenance organization to conduct a 
14         retrospective review of the medical necessity of a 
15         service under certain circumstances; requiring the 
16         health maintenance organization to submit a written 
17         justification for a determination that a service was 
18         not medically necessary and provide a process for 
19         appealing the determination; providing an effective 
20         date. 
21 
22  Be It Enacted by the Legislature of the State of Florida: 
23 
24         Section 1. Section 627.6141, Florida Statutes, is amended 
25  to read: 
26         627.6141 Denial of claims.—Each claimant, or provider 
27  acting for a claimant, who has had a claim denied or a portion 
28  of a claim denied because the provider failed to obtain the 
29  necessary authorization due to an unintentional act or error or 
30  omission as not medically necessary must be provided an 
31  opportunity for an appeal to the insurer’s licensed physician 
32  who is responsible for the medical necessity reviews under the 
33  plan or is a member of the plan’s peer review group. If the 
34  provider appeals the denial, the health insurer shall conduct 
35  and complete a retrospective review of the medical necessity of 
36  the service within 30 business days after the submitted appeal. 
37  If the insurer determines upon review that the service was 
38  medically necessary, the insurer shall reverse the denial and 
39  pay the claim. If the insurer determines that the service was 
40  not medically necessary, the insurer shall submit to the 
41  provider specific written clinical justification for the 
42  determination. The appeal may be by telephone, and the insurer’s 
43  licensed physician must respond within a reasonable time, not to 
44  exceed 15 business days. 
45         Section 2. Subsection (3) of section 641.3156, Florida 
46  Statutes, is renumbered as subsection (4), and a new subsection 
47  (3) is added to that section to read: 
48         641.3156 Treatment authorization; payment of claims.— 
49         (3) If a provider claim or a portion of a provider claim is 
50  denied because the provider, due to an unintentional act of 
51  error or omission, failed to obtain the necessary authorization, 
52  the provider may appeal the denial to the health maintenance 
53  organization’s licensed physician who is responsible for medical 
54  necessity reviews. The health maintenance organization shall 
55  conduct and complete a retrospective review of the medical 
56  necessity of the service within 30 business days after the 
57  submitted appeal. If the health maintenance organization 
58  determines that the service is medically necessary, the health 
59  maintenance organization shall reverse the denial and pay the 
60  claim. If the health maintenance organization determines that 
61  the service is not medically necessary, the health maintenance 
62  organization shall provide the provider with specific written 
63  clinical justification for the determination. 
64         Section 3. This act shall take effect July 1, 2010. 
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