Bill Text: FL S1574 | 2024 | Regular Session | Introduced
Bill Title: Health Care Services
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2024-03-08 - Died in Banking and Insurance [S1574 Detail]
Download: Florida-2024-S1574-Introduced.html
Florida Senate - 2024 SB 1574
By Senator Jones
34-01577-24 20241574__
1 A bill to be entitled
2 An act relating to health care services; amending s.
3 627.42392, F.S.; defining terms; revising the
4 definitions of the terms “health insurer” as
5 “utilization review entity”; requiring utilization
6 review entities to establish and offer a prior
7 authorization process for accepting electronic prior
8 authorization requests by a specified date; specifying
9 a requirement for the process; specifying additional
10 requirements and procedures for, and restrictions and
11 limitations on, utilization review entities relating
12 to prior authorization for covered health care
13 benefits; defining the term “medications for opioid
14 use disorder”; providing construction; creating s.
15 627.4262, F.S.; defining terms; prohibiting payment
16 adjudicators from downcoding health care services
17 under certain circumstances; requiring payment
18 adjudicators to provide certain information prior to
19 making their initial payment or notice of denial of
20 payment; prohibiting downcoding by payment
21 adjudicators for certain orders; providing that a
22 payment adjudicator is solely responsible for certain
23 violations of law; requiring payment adjudicators to
24 maintain downcoding policies on their websites;
25 specifying the requirements of such policies;
26 providing that payment adjudicators are responsible
27 for compliance with certain provisions; requiring
28 payment adjudicators to develop certain internal
29 procedures; authorizing the Office of Insurance
30 Regulation to investigate and take appropriate actions
31 under certain circumstances; providing severability;
32 authorizing a provider to bring a private cause of
33 action under certain circumstances; amending s.
34 627.6131, F.S.; revising the requirements of insurer
35 contracts; revising the definition of the term
36 “claim”; defining terms; revising the requirements for
37 health insurers submitting claims electronically and
38 nonelectronically; making technical changes; deleting
39 the prohibition against waiving, voiding, or
40 nullifying certain provisions by contract; prohibiting
41 a health insurer from retrospectively denying a claim
42 under certain circumstances; revising procedures for
43 investigation of claims of improper billing; providing
44 construction; prohibiting health care insurers from
45 requesting certain information or resubmission of
46 claims under certain circumstances; prohibiting an
47 insurer from requiring information from a provider
48 before the provision of emergency services and care;
49 providing an effective date.
50
51 Be It Enacted by the Legislature of the State of Florida:
52
53 Section 1. Section 627.42392, Florida Statutes, is amended
54 to read:
55 627.42392 Prior authorization.—
56 (1) As used in this section, the term:
57 (a) “Adverse determination” means a decision by a health
58 insurer or utilization review entity to deny, reduce, or
59 terminate health care services furnished or proposed to be
60 furnished to an insured. The term does not include a decision to
61 deny, reduce, or terminate services that were determined to be
62 duplicate bills or that are confirmed with the provider to have
63 been billed in error.
64 (b) “Electronic prior authorization process” does not
65 include transmissions through a facsimile machine.
66 (c) “Emergency health care services” has the same meaning
67 as “emergency services and care” as defined in s. 395.002.
68 (d) “Prior authorization” means the process by which health
69 insurers, third-party payors, or utilization review entities
70 determine the medical necessity of nonemergency health care
71 services before the rendering of such services by the provider.
72 Such prior authorization is authorized by the applicable
73 agreement with the health care provider or such prior
74 authorization is otherwise obtained by a provider that does not
75 have such an agreement. The term also includes a health
76 insurer’s or utilization review entity’s requirement, if such
77 requirement is permitted by the applicable agreement with a
78 health care provider or otherwise permitted by a health care
79 provider that does not have such an agreement, that a patient or
80 health care provider notify the health insurer or utilization
81 review entity before the provision of a nonemergency health care
82 service.
83 (e) “Urgent health care service” means a health care
84 service to treat a medical condition that, if the timeframe for
85 making a nonexpedited prior authorization were to be applied,
86 could, in the opinion of a physician with knowledge of the
87 patient’s medical condition:
88 1. Seriously jeopardize the life or health of the patient
89 or the ability of the patient to regain maximum function; or
90 2. Subject the patient to severe pain that cannot be
91 adequately managed without the care, treatment, or prescription
92 drug that is the subject of the prior authorization request.
93 (f) “Utilization review activity” means any action taken
94 prospective to, concurrent with, or retrospective to the
95 provision of nonemergency health care services to determine
96 whether a claim is paid or is subject to an adverse
97 determination. Utilization review activity is not allowed to the
98 extent restricted or prohibited by an agreement with a health
99 care provider or, other than to verify a presenting emergency
100 medical condition, for emergency health care services. For
101 purposes of this paragraph, the term “a presenting emergency
102 medical condition” means a medical condition manifesting itself
103 by acute symptoms of sufficient severity, including severe pain,
104 such that a prudent layperson who possesses an average knowledge
105 of health and medicine could reasonably expect the absence of
106 immediate medical attention to result in a condition or
107 situation described in s. 395.002(8).
108 (g) “Utilization review entity” “health insurer” means an
109 authorized insurer offering health insurance as defined in s.
110 624.603, a managed care plan as defined in s. 409.962(10), or a
111 health maintenance organization as defined in s. 641.19(12), a
112 pharmacy benefit manager as defined in s. 624.490, or any other
113 individual or entity that provides, offers to provide, or
114 administers payment for hospital services, outpatient services,
115 medical services, prescription drugs, or other health care
116 services to a person treated by a health care professional or
117 facility in this state under a policy, plan, or contract.
118 (2) Beginning January 1, 2025, a utilization review entity
119 shall establish and offer a secure, interactive, online,
120 electronic prior authorization process for accepting electronic
121 prior authorization requests. The process must allow a person
122 seeking prior authorization the ability to upload documentation
123 if such documentation is required by the utilization review
124 entity to make a determination on the prior authorization
125 request.
126 (3) Notwithstanding any other provision of law, effective
127 January 1, 2017, or 6 six (6) months after the effective date of
128 the rule adopting the prior authorization form, whichever is
129 later, a utilization review entity that health insurer, or a
130 pharmacy benefits manager on behalf of the health insurer, which
131 does not provide an electronic prior authorization process for
132 use by its contracted providers, shall use only use the prior
133 authorization form that has been approved by the Financial
134 Services commission for granting a prior authorization for a
135 medical procedure, course of treatment, or prescription drug
136 benefit. Such form may not exceed two pages in length, excluding
137 any instructions or guiding documentation, and must include all
138 clinical documentation necessary for the utilization review
139 entity health insurer to make a decision. At a minimum, the form
140 must include:
141 (a)(1) Sufficient patient information to identify the
142 member, date of birth, full name, and health plan ID number;
143 (b)(2) The provider’s provider name, address, and phone
144 number;
145 (c)(3) The medical procedure, course of treatment, or
146 prescription drug benefit being requested, including the medical
147 reason therefor, and all services tried and failed;
148 (d)(4) Any laboratory documentation required; and
149 (e)(5) An attestation that all information provided is true
150 and accurate.
151 (4)(3) The Financial Services commission, in consultation
152 with the Agency for Health Care Administration, shall adopt by
153 rule guidelines for all prior authorization forms which ensure
154 the general uniformity of such forms.
155 (5)(4) Electronic prior authorization approvals do not
156 preclude benefit verification or medical review by the
157 utilization review entity insurer under either the medical or
158 pharmacy benefits.
159 (6) A utilization review entity’s prior authorization
160 process may not require information that is not needed to make a
161 determination or facilitate a determination of medical necessity
162 of the requested medical procedure, course of treatment, or
163 prescription drug benefit.
164 (7) A utilization review entity shall disclose all of its
165 prior authorization requirements and restrictions, including any
166 written clinical criteria, in a publicly accessible manner on
167 its website. Such information must be explained in detail and in
168 clear and ordinary terms.
169 (8) A utilization review entity may not implement any new
170 requirement or restriction or make changes to existing
171 requirements for or restrictions on obtaining prior
172 authorization unless both of the following conditions are met:
173 (a) The changes have been available on a publicly
174 accessible website for at least 60 days before they are
175 implemented.
176 (b) Insureds and health care providers affected by the new
177 requirements and restrictions or by the changes to the
178 requirements and restrictions are provided with a written notice
179 of the changes at least 60 days before they are implemented.
180 Such notice must be delivered electronically or by other means
181 as agreed to by the insured or the health care provider.
182 (9) A utilization review entity shall make available on its
183 website, in a readily accessible format, data regarding prior
184 authorization approvals and denials, which must include all of
185 the following:
186 (a) All items and services requiring prior authorization.
187 (b) The percentage, in aggregate, of prior authorization
188 requests approved.
189 (c) The percentage, in aggregate, of prior authorization
190 requests denied.
191 (d) The percentage of prior authorization requests approved
192 after appeal.
193 (e) The percentage of prior authorization requests in which
194 the timeframe for review was extended and the prior
195 authorization request was approved.
196 (f) The percentage of expedited prior authorization
197 requests approved.
198 (g) The average and median time between submission of a
199 request for prior authorization and a determination of the
200 outcome.
201 (h) The average and median time between submission of a
202 request for an expedited prior authorization and a determination
203 of the outcome.
204
205 This subsection does not apply to the expansion of health care
206 services coverage.
207 (10) A utilization review entity shall ensure that all
208 adverse determinations are made by a physician licensed pursuant
209 to chapter 458 or chapter 459. All of the following requirements
210 apply to such physicians:
211 (a) The physician must possess a current and valid
212 nonrestricted license to practice medicine in this state.
213 (b) The physician must be of the same specialty as the
214 physician who typically manages the medical condition or disease
215 or who provides the health care service that is the subject of
216 the request.
217 (c) The physician must have experience treating patients
218 with the medical condition or disease for which the health care
219 service is being requested.
220 (11) Notice of an adverse determination must be provided by
221 e-mail to the health care provider that initiated the prior
222 authorization. The notice must include all of the following:
223 (a) The name, title, e-mail address, and telephone number
224 of the physician responsible for making the adverse
225 determination.
226 (b) Any written clinical criteria and any internal rule,
227 guideline, or protocol that the utilization review entity relied
228 upon in making the adverse determination, and how such rule,
229 guideline, or protocol applies to the insured’s specific medical
230 circumstance.
231 (c) Information for the insured and the insured’s health
232 care provider which describes the procedure through which the
233 insured or health care provider may request a copy of any report
234 developed by the health care provider performing the review that
235 led to the adverse determination.
236 (d) An explanation to the insured and the insured’s health
237 care provider of the appeals process for an adverse
238 determination.
239 (12) If a utilization review entity requires prior
240 authorization of a nonemergency health care service, the
241 utilization review entity must make an authorization or adverse
242 determination and notify the insured and the insured’s provider
243 of such service of the decision within 2 business days after
244 obtaining all necessary information to make the authorization or
245 adverse determination. For purposes of this subsection,
246 necessary information includes the results of any face-to-face
247 clinical evaluation or second opinion that may be required.
248 (13) A utilization review entity shall render an expedited
249 authorization or adverse determination concerning an emergency
250 health care service and notify the insured and the insured’s
251 provider of such service of the expedited prior authorization or
252 adverse determination no later than 1 business day after
253 receiving all information needed to complete the review of the
254 requested urgent health care service.
255 (14) A utilization review entity may not require prior
256 authorization for prehospital transportation or for provision of
257 an emergency health care service. A utilization review entity
258 may not conduct any utilization review activity, nor render any
259 adverse determinations, to the extent restricted or prohibited
260 by an agreement with a health care provider. A utilization
261 review entity may not perform any utilization review activity,
262 nor render any adverse determinations, with respect to emergency
263 health care services beyond verification of the presenting
264 emergency medical condition.
265 (15) A utilization review entity may not require prior
266 authorization for the provision of medications for opioid use
267 disorder. As used in this subsection, the term “medications for
268 opioid use disorder” means the use of medications approved by
269 the United States Food and Drug Administration (FDA), commonly
270 in combination with counseling and behavioral therapies, to
271 provide a comprehensive approach to the treatment of opioid use
272 disorder. Such FDA-approved medications used to treat opioid
273 addiction include, but are not limited to, methadone;
274 buprenorphine, alone or in combination with naloxone; and
275 extended-release injectable naltrexone. Such types of behavioral
276 therapies include, but are not limited to, individual therapy,
277 group counseling, family therapy, motivational incentives, and
278 other modalities.
279 (16) A utilization review entity may not revoke, limit,
280 condition, or restrict a prior authorization if care is provided
281 within 45 business days after the date the health care provider
282 received the prior authorization. A utilization review entity
283 shall pay the health care provider at the contracted payment
284 rate for a health care service provided by the health care
285 provider under a prior authorization unless any of the following
286 is true:
287 (a) The health care provider knowingly and materially
288 misrepresented the health care service in the prior
289 authorization request with the specific intent to deceive and
290 obtain an unlawful payment from the utilization review entity.
291 (b) The health care service was no longer a covered benefit
292 on the day it was provided, and the utilization review entity
293 notified the health care provider in writing of this fact before
294 the health care service was provided.
295 (c) The authorized service was never performed.
296 (d) The insured was no longer eligible for health care
297 coverage on the day the care was provided, and the utilization
298 review entity notified the health care provider in writing of
299 this fact before the health care service was provided.
300 (17) If a utilization review entity required a prior
301 authorization for a health care service for the treatment of a
302 chronic or long-term care condition, the prior authorization
303 remains valid for the length of the treatment and the
304 utilization review entity may not require the insured to obtain
305 a prior authorization again for the health care service.
306 (18) A utilization review entity may not impose an
307 additional prior authorization requirement with respect to a
308 surgical or otherwise invasive procedure, or any item furnished
309 as part of such a procedure, if the procedure or item is
310 furnished during the perioperative period of another procedure
311 for which prior authorization was granted by the utilization
312 review entity.
313 (19) Any change in coverage or approval criteria for a
314 previously authorized health care service may not affect an
315 insured who received prior authorization before the effective
316 date of the change for the remainder of the insured’s plan year.
317 (20) A utilization review entity shall continue to honor a
318 prior authorization it has granted to an insured when the
319 insured changes coverage under the same insurance company.
320 (21) Any health care services subject to review are
321 automatically deemed authorized by the utilization review entity
322 if it fails to comply with the deadlines and other requirements
323 specified in this section.
324 (22) Except as otherwise provided in subsection (16), a
325 prior authorization constitutes a conclusive determination of
326 the medical necessity of the authorized health care service and
327 an irrevocable obligation to pay for such authorized health care
328 service.
329 (23) The requirements of this section cannot be waived by
330 contract. Any contractual arrangement or action taken in
331 conflict with this section, or which purports to waive any
332 requirement of this section, is void.
333 (24) This section does not prohibit an agreement with a
334 health care provider to restrict, limit, prohibit, or substitute
335 utilization review activity or prior authorization.
336 Section 2. Section 627.4262, Florida Statutes, is created
337 to read:
338 627.4262 Payment adjudication.—
339 (1) For the purposes of this section, the term:
340 (a) “Downcode” or “downcoding” means the alteration by a
341 payment adjudicator of the service code to another service code
342 or the alteration, addition, or removal by a payment adjudicator
343 of a modifier, when the changed code or modifier is associated
344 with a lower payment amount than the service code or modifier
345 billed by the provider or facility.
346 (b) “Health plan” means any entity that offers health
347 insurance coverage, whether through a fully insured plan or a
348 self-insured plan or fund, including an authorized insurer
349 offering health insurance as defined in s. 624.603, any entity
350 that offers a self-insured fund as described in s. 624.462, or
351 group self-insurance funds as described in 624.4621, a health
352 insurer subject to chapter 627, a managed care plan as defined
353 in s. 409.962, or a health maintenance organization as defined
354 in s. 641.19.
355 (c) “Medical record” means the comprehensive collection of
356 documentation, including clinical notes, diagnostic reports, and
357 other relevant information, which supports the health care
358 services provided.
359 (d) “Participation agreement” means a written contract or
360 agreement between a health plan and a provider which outlines
361 the terms and conditions of participation, reimbursement rates,
362 and other relevant details.
363 (e) “Payment adjudicator” means a health plan or any entity
364 that provides, offers to provide, or administers payment on
365 behalf of a health plan, as well any pharmacy benefit manager as
366 defined in s. 626.88, and any other individual or entity that
367 provides, offers to provide, or administers payment for hospital
368 services, outpatient services, medical services, prescription
369 drugs, or other health care services to a person treated by a
370 health care professional or facility in this state under a
371 policy, plan, or contract.
372 (f) “Provider” includes any health care professional,
373 facility, or entity that submits claims for reimbursement for
374 covered health care services provided to individuals covered
375 under a health plan.
376 (2)(a) Payment adjudicators are prohibited from downcoding
377 a health care service billed by, or on behalf of, a provider, if
378 the health care service was ordered by a provider in-network
379 with the applicable health plan, unless such downcoding is
380 otherwise expressly allowed under the participation agreement
381 between the health plan and such provider.
382 (b) If downcoding is expressly allowed under the
383 participation agreement, the payment adjudicator must first
384 conduct a review of the associated medical record to ensure the
385 accuracy of the coding change, and then provide the following
386 information to the provider before making its initial payment or
387 notice of denial of payment:
388 1. A statement indicating that the service code or modifier
389 billed by the provider or facility is going to be downcoded.
390 2. An explanation detailing the reasons for downcoding the
391 claim. This explanation must include a clear description of the
392 service codes or modifiers that were altered, added, or removed,
393 if applicable.
394 3. The payment amount that the payment adjudicator would
395 otherwise make if the service code or modifier was not
396 downcoded.
397 4. A statement that the provider may contest the downcoding
398 of the applicable service code or modifier by filing a
399 contestation with the payment adjudicator with respect to the
400 downcoding within 15 days after receipt of the statements
401 required under this paragraph.
402 5. A statement that, by contesting the downcoding of the
403 applicable service code or modifier, the provider does not waive
404 any of its legal rights to pursue claims against the health plan
405 or payment adjudicator.
406 (c) A payment adjudicator may not downcode a service code
407 or modifier for services provided pursuant to orders issued by a
408 licensed nurse.
409 (d) Notwithstanding this section, a payment adjudicator
410 that downcodes a service code or modifier, regardless of whether
411 such downcoding is contested by the provider, is solely
412 responsible for any violations of law associated with such
413 downcoding.
414 (3)(a) Payment adjudicators shall maintain clear and
415 accessible downcoding policies on their official websites. These
416 policies must include all of the following:
417 1. An overview of the circumstances under which downcoding
418 may occur.
419 2. The process and criteria used for conducting reviews of
420 downcoded claims, including the role of medical record review.
421 3. Information about the internal mechanisms for ensuring
422 consistency and accuracy in downcoding practices.
423 4. Information regarding the processes for contesting the
424 downcode of a service code with the payment adjudicator.
425 (b) Health plans shall ensure that their downcoding
426 policies are updated, as needed, to reflect any changes in
427 regulations, industry standards, or internal procedures.
428 (4)(a) Payment adjudicators are responsible for ensuring
429 compliance with this section and shall develop internal
430 procedures to implement and adhere to the requirements thereof.
431 (b) The office may investigate and take appropriate actions
432 in cases of noncompliance with this section.
433 (5) If any provision of this section or its application to
434 any person or circumstances is held invalid, the invalidity does
435 not affect other provisions or applications of this section
436 which can be given effect without the invalid provision or
437 application, and to this end the provisions of this section are
438 severable.
439 (6) A provider may bring a private cause of action against
440 the payment adjudicator for a violation of this section.
441 Section 3. Present subsections (18) and (19) of section
442 627.6131, Florida Statutes, are redesignated as subsections (22)
443 and (23), respectively, new subsections (18) and (19) and
444 subsections (20) and (21) are added to that section, and
445 subsections (1) and (2), paragraphs (a) and (c) of subsection
446 (4), paragraphs (a) and (c) of subsection (5), and subsections
447 (6), (10), (11), and (13) of that section are amended, to read:
448 627.6131 Payment of claims.—
449 (1) The contract must shall include the following
450 provision: “Time of Payment of Claims: After receiving written
451 proof of loss, the insurer will pay monthly all claims benefits
452 then due for ...(type of benefit).... Claims Benefits for any
453 other loss covered by this policy will be paid as soon as the
454 insurer receives proper written proof.”
455 (2) As used in this section, the term:
456 (a) “Claim,” for a noninstitutional provider, means a
457 paper, Centers for Medicare and Medicaid Services (CMS) 1500
458 form, or its successor, or electronic billing instrument
459 submitted to the insurer’s designated location which that
460 consists of the ANSI ASC X12N 837P standard HCFA 1500 data set,
461 or its successor, which that has all mandatory entries for a
462 physician licensed under chapter 458, chapter 459, chapter 460,
463 chapter 461, or chapter 463, or psychologists licensed under
464 chapter 490 or any appropriate billing instrument that has all
465 mandatory entries for any other noninstitutional provider. For
466 institutional providers, the term “claim” means a paper or
467 electronic billing instrument submitted to the insurer’s
468 designated location which that consists of the ANSI ASC X12N
469 837P standard UB-92 data set, or its successor, with entries
470 stated as mandatory by the National Uniform Billing Committee.
471 (b) “Clean claim” means a completed form or completed
472 electronic billing instrument referenced in paragraph (a) which
473 contains all of the following information:
474 1. All information required under the applicable form or
475 electronic billing instrument.
476 2. Information reasonably required by the insurer to
477 substantiate the claim, which, except for emergency services and
478 care as defined in s. 641.47, is submitted in advance of the
479 provision of service.
480 (c) “Insured ineligibility” means a circumstance in which
481 an insured is no longer enrolled in the health plan at the time
482 of receiving the applicable service.
483 (d) “Overpayment” means a payment that is billed in error,
484 a duplicate claim, or a payment for a service rendered to a
485 patient for a service because of insured ineligibility.
486 (4) For all electronically submitted claims, a health
487 insurer shall:
488 (a) Within 24 hours after the beginning of the next
489 business day after receipt of the claim, provide, to the
490 electronic source submitting the claim, an electronic
491 acknowledgment of the receipt of the claim along with its
492 position as to whether the claim is a clean claim or whether the
493 claim is missing any information required under the applicable
494 electronic billing instrument provided in paragraph (2)(a) or
495 that was reasonably required by the insurer in advance of the
496 provision of service, other than emergency services and care as
497 defined in s. 641.47, to substantiate the claim to the
498 electronic source submitting the claim.
499 (c)1. Notification of the health insurer’s determination of
500 a contested claim must be accompanied by an itemized list of any
501 additional information required under the applicable billing
502 instrument specified in paragraph (2)(a) or which was reasonably
503 required by the insurer and the health insurer asserts is still
504 missing as of the date of such service, other than for emergency
505 services and care as defined in s. 641.47 or documents the
506 insurer can reasonably determine are necessary to process the
507 claim.
508 2. A provider must submit the additional information or
509 documentation, as specified on the itemized list, within 35 days
510 after receipt of the notification unless within such 35-day
511 period the provider notifies the insurer of its position that a
512 clean claim has been submitted. Additional information is
513 considered submitted on the date it is electronically
514 transferred or mailed. The health insurer may not request
515 duplicate documents.
516 (5) For all nonelectronically submitted claims, a health
517 insurer shall:
518 (a) Effective November 1, 2003, Provide to the provider
519 submitting the claim an acknowledgment of receipt of the claim
520 along with its position as to whether the claim is a clean claim
521 or whether the claim is missing any information required under
522 the applicable paper billing form described in paragraph (2)(a)
523 which was reasonably required by the insurer to substantiate the
524 claim in advance of the provision of service, other than for
525 emergency services and care as defined in s. 641.47, within 15
526 days after receipt of the claim to the provider or provide a
527 provider within 15 days after receipt with electronic access to
528 the status of a submitted claim.
529 (c)1. Notification of the health insurer’s determination of
530 a contested claim must be accompanied by an itemized list of any
531 additional information required under the applicable billing
532 instrument described in paragraph (2)(a) or which was reasonably
533 required by the insurer to substantiate the claim in advance of
534 the provision of service, other than for emergency services and
535 care as defined in s. 641.47, which the health insurer asserts
536 is still missing as of the date of such service or documents the
537 insurer can reasonably determine are necessary to process the
538 claim.
539 2. A provider must submit the additional information or
540 documentation, as specified on the itemized list, within 35 days
541 after receipt of the notification unless, within such 35-day
542 period, the provider notifies the insurer of its position that a
543 clean claim has been submitted. Additional Information is
544 considered submitted on the date it is electronically
545 transferred or mailed. The health insurer may not request
546 duplicate documents.
547 (6) If a health insurer determines that it has made an
548 overpayment to a provider for services rendered to an insured,
549 the health insurer must make a claim for such overpayment to the
550 provider’s designated location. A health insurer that makes a
551 claim for overpayment to a provider under this section shall
552 give the provider a written or electronic statement specifying
553 the basis for the retrospective retroactive denial or payment
554 adjustment. The insurer must identify the claim or claims, or
555 overpayment claim portion thereof, for which a claim for
556 overpayment is submitted.
557 (a) If an overpayment determination is the result of
558 retrospective retroactive review or retrospective audit of
559 coverage decisions or payment levels not related to fraud, a
560 health insurer must shall adhere to all of the following
561 procedures:
562 1. All claims for overpayment must be submitted to a
563 provider within 30 months after the health insurer’s payment of
564 the claim. A provider must pay, deny, or contest the health
565 insurer’s claim for overpayment within 40 days after the receipt
566 of the claim. All contested claims for overpayment must be paid
567 or denied within 120 days after receipt of the claim. Failure to
568 pay or deny overpayment and claim within 140 days after receipt
569 creates an uncontestable obligation to pay the claim.
570 2. A provider that denies or contests a health insurer’s
571 claim for overpayment or any portion of a claim shall notify the
572 health insurer, in writing, within 35 days after the provider
573 receives the claim that the claim for overpayment is contested
574 or denied. The notice that the claim for overpayment is denied
575 or contested must identify the contested portion of the claim
576 and the specific reason for contesting or denying the claim and,
577 if contested, must include a request for additional information.
578 If the health insurer submits additional information, the health
579 insurer must, within 35 days after receipt of the request, mail
580 or electronically transfer the information to the provider. The
581 provider shall pay or deny the claim for overpayment within 45
582 days after receipt of the information. The notice is considered
583 made on the date the notice is mailed or electronically
584 transferred by the provider.
585 3. The health insurer may not reduce payment to the
586 provider for other services unless the provider agrees to the
587 reduction in writing or fails to respond to the health insurer’s
588 overpayment claim as required by this paragraph.
589 4. Payment of an overpayment claim is considered made on
590 the date the payment was mailed or electronically transferred.
591 An overdue payment of a claim bears simple interest at the rate
592 of 12 percent per year. Interest on an overdue payment for a
593 claim for an overpayment begins to accrue when the claim should
594 have been paid, denied, or contested.
595 (b) A claim for overpayment shall not be permitted beyond
596 30 months after the health insurer’s payment of a claim, except
597 that claims for overpayment may be sought beyond that time from
598 providers convicted of fraud pursuant to s. 817.234.
599 (10) The provisions of this section may not be waived,
600 voided, or nullified by contract.
601 (10)(11) A health insurer may not retrospectively
602 retroactively deny a claim because of insured ineligibility more
603 than 90 days 1 year after the date of payment of the claim.
604 (12)(13) Upon written notification by an insured, an
605 insurer shall investigate any claim of improper billing of the
606 insured by a physician, hospital, or other health care provider
607 for a health care service alleged not to have been received. The
608 insurer shall determine if the insured received such service was
609 properly billed for only those procedures and services that the
610 insured actually received. If the insurer determines that the
611 insured did not receive the service has been improperly billed,
612 the insurer must shall notify the insured and the provider of
613 its findings and shall reduce the amount of payment to the
614 provider by the amount charged for the service that was not
615 received determined to be improperly billed. If a reduction is
616 made due to such notification by the insured, the insurer shall
617 pay to the insured 20 percent of the amount of the reduction up
618 to $500.
619 (18) This section may not be interpreted to limit,
620 restrict, or negatively impact any legal claim by a provider or
621 insurer for breach of contract, statutory or regulatory
622 violation, or under a common law cause of action, or shorten or
623 otherwise negatively impact the statute of limitations timeframe
624 for bringing any such legal claim.
625 (19) A health insurer may not request information from a
626 contracted or noncontracted provider which does not apply to the
627 medical condition at issue for the purposes of making a
628 determination of a clean claim.
629 (20) A health insurer may not request a contracted or
630 noncontracted provider to resubmit claim information that the
631 contracted or noncontracted provider can document it has already
632 provided to the health insurer.
633 (21) Notwithstanding any law to the contrary, an insurer
634 may not require any information from a provider before the
635 provision of emergency services and care as defined in s. 641.47
636 as a condition of payment of a claim, as a basis for denying or
637 reducing payment of a claim, or in contesting whether the claim
638 is a clean claim.
639 Section 4. This act shall take effect July 1, 2024.
