Senate Bill 1752
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Florida Senate - 1998 SB 1752
By Senators Cowin and Williams
11-957A-98 See HB
1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 636.003, F.S.; providing a definition;
4 amending s. 636.009, F.S.; providing an
5 additional condition upon issuance of a
6 certificate of authority under certain
7 circumstances; amending s. 636.016, F.S.;
8 requiring the provision of certain information;
9 amending s. 636.035, F.S.; clarifying
10 limitations on certain provider arrangements;
11 amending s. 636.038, F.S.; specifying
12 procedures and requirements for grievance
13 reporting and resolution; providing duties and
14 responsibilities of the Department of
15 Insurance; providing an effective date.
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17 Be It Enacted by the Legislature of the State of Florida:
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19 Section 1. Present subsections (1) through (17) of
20 section 636.003, Florida Statutes, are renumbered as
21 subsections (2) through (18), respectively, and a new
22 subsection (1) is added to that section, to read:
23 636.003 Definitions.--As used in this act, the term:
24 (1) "Adverse determination" means a coverage
25 determination by a prepaid limited health service organization
26 that an admission, availability of care, continued stay, or
27 other health care service has been reviewed and, based upon
28 the information provided, does not meet the organization's
29 requirements for medical necessity, appropriateness, health
30 care setting, level of care, or effectiveness, and coverage
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Florida Senate - 1998 SB 1752
11-957A-98 See HB
1 for the requested service is therefore denied, reduced, or
2 terminated, or an alternative benefit is applied.
3 Section 2. Paragraph (m) is added to subsection (1) of
4 section 636.009, Florida Statutes, to read:
5 636.009 Issuance of certificate of authority;
6 denial.--
7 (1) Following receipt of an application filed pursuant
8 to s. 636.008, the department shall review such application
9 and notify the applicant of any deficiencies contained
10 therein. The department shall issue a certificate of
11 authority to an applicant who has filed a completed
12 application in conformity with s. 636.008, upon payment of the
13 fees specified by s. 636.057 and upon the department being
14 satisfied that the following conditions are met:
15 (m) In the case of a prepaid limited health services
16 organization offering dental services, that a dental director,
17 who is a dentist licensed under chapter 466, has been
18 designated.
19 Section 3. Subsection (13) is added to section
20 636.016, Florida Statutes, to read:
21 636.016 Prepaid limited health service contracts.--For
22 any entity licensed prior to October 1, 1993, all subscriber
23 contracts in force at such time shall be in compliance with
24 this section upon renewal of such contract.
25 (13) Each prepaid limited health service organization
26 shall make available to each subscriber, upon request, a
27 detailed description of the process the organization uses to
28 authorize and refer services, determine whether services are
29 medically necessary, determine when alternative services are
30 applied, or examine the qualifications and credentials of
31 providers under contract with the organization. Such
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Florida Senate - 1998 SB 1752
11-957A-98 See HB
1 organization shall immediately report to the department any
2 change by the organization in any such process or in the
3 organization's definition of "medically necessary" or
4 "alternative services."
5 Section 4. Subsections (2) and (3) of section 636.035,
6 Florida Statutes, are amended to read:
7 636.035 Provider arrangements.--
8 (2) A No subscriber, who is in good standing, of a
9 prepaid limited health service organization is not liable to
10 any provider who has contracted with the prepaid limited of
11 health service organization care services for any services
12 covered by the prepaid limited health service organization
13 with which the subscriber and provider have contracted.
14 (3) A No provider who has contracted with a of prepaid
15 limited health care service organization services or any
16 representative of such provider may not collect or attempt to
17 collect from a subscriber, who is in good standing, any money
18 for services covered by a prepaid limited health service
19 organization with whom the provider has contracted, and no
20 provider or representative of such provider may maintain any
21 action against a subscriber of the a prepaid limited health
22 service organization to collect money owed to such provider by
23 the a prepaid limited health service organization.
24 Section 5. Section 636.038, Florida Statutes, is
25 amended to read:
26 Substantial rewording of section. See
27 s. 636.038, F.S., for present text.
28 636.038 Subscriber grievance reporting and resolution
29 requirements.--
30 (1) For purposes of this section, organization means a
31 prepaid limited health service organization. Each organization
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Florida Senate - 1998 SB 1752
11-957A-98 See HB
1 must have a grievance procedure available to its subscribers
2 for the purpose of addressing complaints and grievances. Each
3 organization must notify its subscribers that a subscriber
4 must submit a grievance within 1 year after the date of
5 occurrence of the action that initiated the grievance and may
6 submit the grievance for review to the department after
7 receiving a final disposition of the grievance through the
8 organization's grievance process. An organization shall
9 maintain records of all grievances and shall report annually
10 to the department the total number of grievances handled, a
11 categorization of the cases underlying the grievances, and the
12 final disposition of the grievances.
13 (2) When an organization receives an initial complaint
14 from a subscriber, the organization must respond to the
15 complaint within a reasonable time after its submission. At
16 the time of receipt of the initial complaint, the organization
17 shall inform the subscriber that the subscriber has a right to
18 file a written grievance at any time and that assistance in
19 preparing the written grievance shall be provided by the
20 organization.
21 (3) Each organization's grievance procedure, as
22 required under subsection (1), must include, at a minimum:
23 (a) An explanation of how to pursue redress of a
24 grievance.
25 (b) The names of the appropriate employees or a list
26 of grievance departments that are responsible for implementing
27 the organization's grievance procedure. The list must include
28 the address and the toll-free telephone number of each
29 grievance department and the address of the department and its
30 toll-free telephone hotline number.
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Florida Senate - 1998 SB 1752
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1 (c) A description of the process through which a
2 subscriber may, at any time, contact the toll-free telephone
3 hotline of the department to inform it of the unresolved
4 grievance, the toll-free telephone number of the department's
5 consumer services hotline, and a description of how consumer
6 services may assist in resolving the grievance.
7 (d) A process whereby the grievance manager
8 acknowledges the grievance and investigates the grievance in
9 order to notify the subscriber of a final decision in writing.
10 (e) A procedure for providing individuals who are
11 unable to submit a written grievance with access to the
12 grievance process, which shall include assistance by the
13 organization in preparing the grievance and communicating back
14 to the subscriber.
15 (4)(a) With respect to a grievance concerning an
16 adverse determination, an organization shall make available to
17 the subscriber a review of the grievance by an internal review
18 panel; such review must be requested within 30 days after the
19 organization's transmittal of the final determination notice
20 of an adverse determination. A majority of the panel shall be
21 persons who previously were not involved in the initial
22 adverse determination. A person who previously was involved
23 in the adverse determination may appear before the panel to
24 present information or answer questions. The panel shall have
25 the authority to bind the organization to the panel's
26 decision.
27 (b) An organization shall ensure that a majority of
28 the persons reviewing a grievance involving an adverse
29 determination are providers who have appropriate expertise.
30 An organization shall issue a copy of the written decision of
31 the review panel to the subscriber and to the provider, if
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Florida Senate - 1998 SB 1752
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1 any, who submits a grievance on behalf of a subscriber. In
2 cases where there has been a denial of coverage of service,
3 the reviewing provider shall not be a provider previously
4 involved with the adverse determination.
5 (c) An organization shall establish written procedures
6 for a review of an adverse determination. Review procedures
7 shall be available to the subscriber and to a provider acting
8 on behalf of a subscriber.
9 (d) In any case when the review process does not
10 resolve a difference of opinion between the organization and
11 the subscriber or the provider acting on behalf of the
12 subscriber, the subscriber or the provider acting on behalf of
13 the subscriber may submit a written grievance to the
14 department.
15 (5) Except as provided in subsection (6), the
16 organization shall resolve a grievance within 60 days after
17 receipt of the grievance, or within a maximum of 90 days if
18 the grievance involves the collection of information outside
19 the service area. These time limitations are tolled if the
20 organization has notified the subscriber, in writing, that
21 additional information is required for proper review of the
22 grievance and that such time limitations are tolled until such
23 information is provided. After the organization receives the
24 requested information, the time allowed for completion of the
25 grievance process resumes.
26 (6) An organization shall establish written procedures
27 for the expedited review of an urgent grievance. In an
28 expedited review, an organization shall make a decision and
29 notify the subscriber, or the provider acting on behalf of the
30 subscriber, as expeditiously as the subscriber's medical
31 condition requires, but in no event more than 72 hours after
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Florida Senate - 1998 SB 1752
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1 receipt of the request for review. If the expedited review is
2 a concurrent review determination, the service shall be
3 continued without liability to the subscriber until the
4 subscriber has been notified of the determination.
5 (7) The department shall investigate all reports of
6 unresolved quality of care grievances received from review
7 requests of subscribers whose grievances remain unresolved
8 after the subscriber has followed the full grievance procedure
9 of the organization.
10 (8)(a) The department shall advise subscribers with
11 grievances to follow their organization's formal grievance
12 process for resolution prior to review by the department. The
13 subscriber may, however, submit a copy of the grievance to the
14 department at any time during the process.
15 (b) Requiring completion of the organization's
16 grievance process before the department's review does not
17 preclude the department from investigating any complaint or
18 grievance before the organization makes its final
19 determination.
20 (9) Each organization must notify the subscriber in a
21 final decision letter that the subscriber may request review
22 of the organization's decision concerning the grievance by the
23 department, if the grievance is not resolved to the
24 satisfaction of the subscriber. The final decision letter must
25 inform the subscriber that the request for review must be made
26 within 365 days after receipt of the final decision letter,
27 must explain how to initiate such a review, and must include
28 the address and toll-free telephone number of the department.
29 (10) The department may impose administrative
30 sanctions, in accordance with s. 636.048, against an
31 organization for noncompliance with this section.
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Florida Senate - 1998 SB 1752
11-957A-98 See HB
1 Section 6. This act shall take effect October 1 of the
2 year in which enacted.
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5 LEGISLATIVE SUMMARY
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Requires prepaid limited health service organizations to
7 provide descriptions of processes for authorizing and
referring services, determining medical necessity, and
8 determining application of alternative services.
Specifies requirements and criteria for grievance
9 reporting and resolution. (See bill for details.)
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