House Bill 3731
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Florida House of Representatives - 1998 HB 3731
By Representative Byrd
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; amending s. 627.638, F.S.;
16 prohibiting refusal to pay certain benefits
17 under certain circumstances; providing an
18 effective date.
19
20 Be It Enacted by the Legislature of the State of Florida:
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22 Section 1. Subsections (1)-(17) of section 636.003,
23 Florida Statutes, are renumbered as subsections (2)-(18), and
24 a new subsection (1) is added to said section, to read:
25 636.003 Definitions.--As used in this act, the term:
26 (1) "Adverse determination" means a coverage
27 determination by a prepaid limited health service organization
28 that an admission, availability of care, continued stay, or
29 other health care service has been reviewed and, based upon
30 the information provided, does not meet the organization's
31 requirements for medical necessity, appropriateness, health
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1 care setting, level of care, or effectiveness, and coverage
2 for the requested service is therefore denied, reduced, or
3 terminated, or an alternative benefit is applied.
4 Section 2. Paragraph (m) is added to subsection (1) of
5 section 636.009, Florida Statutes, to read:
6 636.009 Issuance of certificate of authority;
7 denial.--
8 (1) Following receipt of an application filed pursuant
9 to s. 636.008, the department shall review such application
10 and notify the applicant of any deficiencies contained
11 therein. The department shall issue a certificate of
12 authority to an applicant who has filed a completed
13 application in conformity with s. 636.008, upon payment of the
14 fees specified by s. 636.057 and upon the department being
15 satisfied that the following conditions are met:
16 (m) In the case of a prepaid limited health services
17 organization offering dental services, that a dental director,
18 who is a dentist licensed under chapter 466, has been
19 designated.
20 Section 3. Subsection (13) is added to section
21 636.016, Florida Statutes, to read:
22 636.016 Prepaid limited health service contracts.--For
23 any entity licensed prior to October 1, 1993, all subscriber
24 contracts in force at such time shall be in compliance with
25 this section upon renewal of such contract.
26 (13) Each prepaid limited health service organization
27 shall make available to each subscriber, upon request, a
28 detailed description of the process the organization uses to
29 authorize and refer services, determine whether services are
30 medically necessary, determine when alternative services are
31 applied, or examine the qualifications and credentials of
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1 providers under contract with the organization. Such
2 organization shall immediately report to the department any
3 change by the organization in any such process or in the
4 organization's definition of "medically necessary" or
5 "alternative services."
6 Section 4. Subsections (2) and (3) of section 636.035,
7 Florida Statutes, are amended to read:
8 636.035 Provider arrangements.--
9 (2) A No subscriber, who is in good standing, of a
10 prepaid limited health service organization is not liable to
11 any provider who has contracted with the prepaid limited of
12 health service organization care services for any services
13 covered by the prepaid limited health service organization
14 with which the subscriber and provider have contracted.
15 (3) A No provider who has contracted with a of prepaid
16 limited health care service organization services or any
17 representative of such provider may not collect or attempt to
18 collect from a subscriber, who is in good standing, any money
19 for services covered by a prepaid limited health service
20 organization with whom the provider has contracted, and no
21 provider or representative of such provider may maintain any
22 action against a subscriber of the a prepaid limited health
23 service organization to collect money owed to such provider by
24 the a prepaid limited health service organization.
25 Section 5. Section 636.038, Florida Statutes, is
26 amended to read:
27 Substantial rewording of section. See
28 s. 636.038, F.S., for present text.
29 636.038 Subscriber grievance reporting and resolution
30 requirements.--
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1 (1) For purposes of this section, organization means a
2 prepaid limited health service organization. Each organization
3 must have a grievance procedure available to its subscribers
4 for the purpose of addressing complaints and grievances. Each
5 organization must notify its subscribers that a subscriber
6 must submit a grievance within 1 year after the date of
7 occurrence of the action that initiated the grievance and may
8 submit the grievance for review to the department after
9 receiving a final disposition of the grievance through the
10 organization's grievance process. An organization shall
11 maintain records of all grievances and shall report annually
12 to the department the total number of grievances handled, a
13 categorization of the cases underlying the grievances, and the
14 final disposition of the grievances.
15 (2) When an organization receives an initial complaint
16 from a subscriber, the organization must respond to the
17 complaint within a reasonable time after its submission. At
18 the time of receipt of the initial complaint, the organization
19 shall inform the subscriber that the subscriber has a right to
20 file a written grievance at any time and that assistance in
21 preparing the written grievance shall be provided by the
22 organization.
23 (3) Each organization's grievance procedure, as
24 required under subsection (1), must include, at a minimum:
25 (a) An explanation of how to pursue redress of a
26 grievance.
27 (b) The names of the appropriate employees or a list
28 of grievance departments that are responsible for implementing
29 the organization's grievance procedure. The list must include
30 the address and the toll-free telephone number of each
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1 grievance department and the address of the department and its
2 toll-free telephone hotline number.
3 (c) A description of the process through which a
4 subscriber may, at any time, contact the toll-free telephone
5 hotline of the department to inform it of the unresolved
6 grievance, the toll-free telephone number of the department's
7 consumer services hotline, and a description of how consumer
8 services may assist in resolving the grievance.
9 (d) A process whereby the grievance manager
10 acknowledges the grievance and investigates the grievance in
11 order to notify the subscriber of a final decision in writing.
12 (e) A procedure for providing individuals who are
13 unable to submit a written grievance with access to the
14 grievance process, which shall include assistance by the
15 organization in preparing the grievance and communicating back
16 to the subscriber.
17 (4)(a) With respect to a grievance concerning an
18 adverse determination, an organization shall make available to
19 the subscriber a review of the grievance by an internal review
20 panel; such review must be requested within 30 days after the
21 organization's transmittal of the final determination notice
22 of an adverse determination. A majority of the panel shall be
23 persons who previously were not involved in the initial
24 adverse determination. A person who previously was involved
25 in the adverse determination may appear before the panel to
26 present information or answer questions. The panel shall have
27 the authority to bind the organization to the panel's
28 decision.
29 (b) An organization shall ensure that a majority of
30 the persons reviewing a grievance involving an adverse
31 determination are providers who have appropriate expertise.
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1 An organization shall issue a copy of the written decision of
2 the review panel to the subscriber and to the provider, if
3 any, who submits a grievance on behalf of a subscriber. In
4 cases where there has been a denial of coverage of service,
5 the reviewing provider shall not be a provider previously
6 involved with the adverse determination.
7 (c) An organization shall establish written procedures
8 for a review of an adverse determination. Review procedures
9 shall be available to the subscriber and to a provider acting
10 on behalf of a subscriber.
11 (d) In any case when the review process does not
12 resolve a difference of opinion between the organization and
13 the subscriber or the provider acting on behalf of the
14 subscriber, the subscriber or the provider acting on behalf of
15 the subscriber may submit a written grievance to the
16 department.
17 (5) Except as provided in subsection (6), the
18 organization shall resolve a grievance within 60 days after
19 receipt of the grievance, or within a maximum of 90 days if
20 the grievance involves the collection of information outside
21 the service area. These time limitations are tolled if the
22 organization has notified the subscriber, in writing, that
23 additional information is required for proper review of the
24 grievance and that such time limitations are tolled until such
25 information is provided. After the organization receives the
26 requested information, the time allowed for completion of the
27 grievance process resumes.
28 (6) An organization shall establish written procedures
29 for the expedited review of an urgent grievance. In an
30 expedited review, an organization shall make a decision and
31 notify the subscriber, or the provider acting on behalf of the
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1 subscriber, as expeditiously as the subscriber's medical
2 condition requires, but in no event more than 72 hours after
3 receipt of the request for review. If the expedited review is
4 a concurrent review determination, the service shall be
5 continued without liability to the subscriber until the
6 subscriber has been notified of the determination.
7 (7) The department shall investigate all reports of
8 unresolved quality of care grievances received from review
9 requests of subscribers whose grievances remain unresolved
10 after the subscriber has followed the full grievance procedure
11 of the organization.
12 (8)(a) The department shall advise subscribers with
13 grievances to follow their organization's formal grievance
14 process for resolution prior to review by the department. The
15 subscriber may, however, submit a copy of the grievance to the
16 department at any time during the process.
17 (b) Requiring completion of the organization's
18 grievance process before the department's review does not
19 preclude the department from investigating any complaint or
20 grievance before the organization makes its final
21 determination.
22 (9) Each organization must notify the subscriber in a
23 final decision letter that the subscriber may request review
24 of the organization's decision concerning the grievance by the
25 department, if the grievance is not resolved to the
26 satisfaction of the subscriber. The final decision letter must
27 inform the subscriber that the request for review must be made
28 within 365 days after receipt of the final decision letter,
29 must explain how to initiate such a review, and must include
30 the address and toll-free telephone number of the department.
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1 (10) The department may impose administrative
2 sanctions, in accordance with s. 636.048, against an
3 organization for noncompliance with this section.
4 Section 6. Subsection (3) is added to section 627.638,
5 Florida Statutes, to read:
6 627.638 Direct payment for hospital, medical
7 services.--
8 (3) Any health insurer, preferred provider
9 organization, exclusive provider organization, or other
10 arrangement which authorizes treatment outside an exclusive
11 list of providers and which provides payment of benefits to a
12 hospital, doctor, or other person who renders covered services
13 shall not refuse payment of benefits solely because the entity
14 providing covered services was not a contracting provider.
15 Section 7. This act shall take effect October 1 of the
16 year in which enacted.
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19 HOUSE SUMMARY
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Requires prepaid limited health service organizations to
21 provide descriptions of processes for authorizing and
referring services, determining medical necessity, and
22 determining application of alternative services.
Specifies requirements and criteria for grievance
23 reporting and resolution. Prohibits health care insurers
or arrangements from refusing to pay benefits to
24 noncontracting providers which provide covered services
under specified circumstances. See bill for details.
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