Senate Bill 1508c2
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Florida Senate - 2000 CS for CS for SB 1508
By the Committees on Health, Aging and Long-Term Care; Banking
and Insurance; and Senator Brown-Waite
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1 A bill to be entitled
2 An act relating to managed care organizations;
3 amending s. 641.315, F.S.; deleting provisions
4 relating to provider billings; revising
5 provisions relating to provider contracts;
6 providing for certain disclosures and requiring
7 notice; requiring procedures for requesting and
8 granting authorization for utilization of
9 services; creating s. 641.3154, F.S.; providing
10 for health maintenance organization liability
11 for payment for services rendered to
12 subscribers; prohibiting provider billing of
13 subscribers under specified circumstances;
14 amending s. 641.3155, F.S.; defining the term
15 "clean claim"; specifying the basis for
16 determining when a claim is to be considered
17 clean or not clean; requiring the Department of
18 Insurance to adopt rules to establish a claim
19 form; providing requirements; providing the
20 Department of Insurance with discretionary
21 rulemaking authority for coding standards;
22 providing requirements; providing for payment
23 of clean claims; providing requirements for
24 denying or contesting a portion of a claim;
25 providing for interest accrual and payment of
26 interest; providing an uncontestable obligation
27 to pay a claim; requiring a health maintenance
28 organization to make a claim for overpayment;
29 prohibiting an organization from reducing
30 payment for other services; providing
31 exceptions; requiring a provider to pay a claim
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1 for overpayment within a specified timeframe;
2 providing a procedure and timeframes for a
3 provider to notify a health maintenance
4 organization that it is denying or contesting a
5 claim for overpayment; specifying when a
6 provider payment of a claim for overpayment is
7 to be considered made; providing for assessment
8 of simple interest against overdue payment of a
9 claim; specifying when interest on overdue
10 payments of claims for overpayment begins to
11 accrue; specifying a timeframe for a provider
12 to deny or contest a claim for overpayment;
13 providing an uncontestable obligation to pay a
14 claim; specifying when a provider claim that is
15 electronically transmitted or mailed is
16 considered received; specifying when a health
17 maintenance organization claim for overpayment
18 is considered received; mandating
19 acknowledgment of receipts for electronically
20 submitted provider claims; prescribing a
21 timeframe for a health maintenance organization
22 to retroactively deny a claim for services
23 provided to an ineligible subscriber; creating
24 s. 641.3156, F.S.; providing for treatment
25 authorization and payment of claims by a health
26 maintenance organization; clarifying that
27 treatment authorization and payment of a claim
28 for emergency services is subject to another
29 provision of law; providing a cross-reference;
30 amending s. 641.495, F.S.; revising provisions
31 relating to treatment-authorization
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1 capabilities; requiring agreement to pending
2 authorizations and tracking numbers as a
3 precondition to such an authorization; creating
4 s. 408.7057, F.S.; providing for the
5 establishment of a statewide provider and
6 managed-care-organization claim-dispute
7 resolution program; providing rulemaking
8 authority to the Agency for Health Care
9 Administration; amending s. 395.1065, F.S.,
10 relating to criminal and administrative
11 penalties for health care providers;
12 authorizing administrative sanctions against a
13 hospital's license for improper subscriber
14 billing and violations of requirements relating
15 to claims payment; amending s. 817.50, F.S.,
16 relating to fraud against hospitals; expanding
17 applicability to health care providers;
18 providing a cross-reference; providing
19 applicability; providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Section 641.315, Florida Statutes, is
24 amended to read:
25 641.315 Provider contracts.--
26 (1) Whenever a contract exists between a health
27 maintenance organization and a provider and the organization
28 fails to meet its obligations to pay fees for services already
29 rendered to a subscriber, the health maintenance organization
30 shall be liable for such fee or fees rather than the
31 subscriber; and the contract shall so state.
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1 (2) No subscriber of an HMO shall be liable to any
2 provider of health care services for any services covered by
3 the HMO.
4 (3) No provider of services or any representative of
5 such provider shall collect or attempt to collect from an HMO
6 subscriber any money for services covered by an HMO and no
7 provider or representative of such provider may maintain any
8 action at law against a subscriber of an HMO to collect money
9 owed to such provider by an HMO.
10 (1)(4) Each Every contract between a health
11 maintenance organization an HMO and a provider of health care
12 services must shall be in writing and shall contain a
13 provision that the subscriber is shall not be liable to the
14 provider for any services for which the health maintenance
15 organization is liable, as specified in s. 641.3154 covered by
16 the subscriber's contract with the HMO.
17 (5) The provisions of this section shall not be
18 construed to apply to the amount of any deductible or
19 copayment which is not covered by the contract of the HMO.
20 (2)(6)(a) For all provider contracts executed after
21 October 1, 1991, and within 180 days after October 1, 1991,
22 for contracts in existence as of October 1, 1991:
23 1. The contracts must require provide that the
24 provider to give shall provide 60 days' advance written notice
25 to the health maintenance organization and the department
26 before canceling the contract with the health maintenance
27 organization for any reason; and
28 2. The contract must also provide that nonpayment for
29 goods or services rendered by the provider to the health
30 maintenance organization is shall not be a valid reason for
31 avoiding the 60-day advance notice of cancellation.
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1 (b) For all provider contracts executed after October
2 1, 1996, and within 180 days after October 1, 1996, for
3 contracts in existence as of October 1, 1996, the contracts
4 must provide that the health maintenance organization will
5 provide 60 days' advance written notice to the provider and
6 the department before canceling, without cause, the contract
7 with the provider, except in a case in which a patient's
8 health is subject to imminent danger or a physician's ability
9 to practice medicine is effectively impaired by an action by
10 the Board of Medicine or other governmental agency.
11 (3)(7) Upon receipt by the health maintenance
12 organization of a 60-day cancellation notice, the health
13 maintenance organization may, if requested by the provider,
14 terminate the contract in less than 60 days if the health
15 maintenance organization is not financially impaired or
16 insolvent.
17 (4) Whenever a contract exists between a health
18 maintenance organization and a provider, the health
19 maintenance organization shall disclose to the provider:
20 (a) The mailing address or electronic address where
21 claims should be sent for processing;
22 (b) The telephone number that a provider may call to
23 have questions and concerns regarding claims addressed; and
24 (c) The address of any separate claims-processing
25 centers for specific types of services.
26
27 A health maintenance organization shall provide to its
28 contracted providers in no less than 30 calendar days, prior
29 written notice of any changes in the information required in
30 this subsection.
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1 (5)(8) A contract between a health maintenance
2 organization and a provider of health care services may shall
3 not restrict contain any provision restricting the provider's
4 ability to communicate information to the provider's patient
5 regarding medical care or treatment options for the patient
6 when the provider deems knowledge of such information by the
7 patient to be in the best interest of the health of the
8 patient.
9 (6)(9) A contract between a health maintenance
10 organization and a provider of health care services may not
11 contain any provision that in any way prohibits or restricts:
12 (a) The health care provider from entering into a
13 commercial contract with any other health maintenance
14 organization; or
15 (b) The health maintenance organization from entering
16 into a commercial contract with any other health care
17 provider.
18 (7)(10) A health maintenance organization or health
19 care provider may not terminate a contract with a health care
20 provider or health maintenance organization unless the party
21 terminating the contract provides the terminated party with a
22 written reason for the contract termination, which may include
23 termination for business reasons of the terminating party. The
24 reason provided in the notice required by in this section or
25 any other information relating to the reason for termination
26 does not create any new administrative or civil action and may
27 not be used as substantive evidence in any such action, but
28 may be used for impeachment purposes. As used in this
29 subsection, the term "health care provider" means a physician
30 licensed under chapter 458, chapter 459, chapter 460, or
31 chapter 461, or a dentist licensed under chapter 466.
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1 (8) A contract between a health maintenance
2 organization and a provider must establish procedures for a
3 provider to request and the health maintenance organization to
4 grant authorization for utilization of health care services.
5 The health maintenance organization must give written notice
6 to the provider prior to any changes in these procedures.
7 Section 2. Section 641.3154, Florida Statutes, is
8 created to read:
9 641.3154 Organization liability; provider billing
10 prohibited.--
11 (1) If a health maintenance organization is liable for
12 services rendered to a subscriber by a provider, whether a
13 contract exists between the organization and the provider or
14 not, the organization is liable for payment of fees to the
15 provider, and the subscriber is not liable for payment of fees
16 to the provider.
17 (2) For purposes of this section, a health maintenance
18 organization is liable for services rendered to a subscriber
19 by a provider if the subscriber contract or applicable law
20 establishes such liability.
21 (3) The liability of an organization for payment of
22 fees for services is not affected by any contract the
23 organization has with a third party for the functions of
24 authorizing, processing, or paying claims.
25 (4) A provider, whether under contract with the health
26 maintenance organization or not, or any representative of such
27 provider, may not collect or attempt to collect money from,
28 maintain any action at law against, or report to a credit
29 agency a subscriber of an organization for payment of services
30 for which the organization is liable, if the provider in good
31 faith knows or should know that the organization is liable.
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1 This prohibition applies during the pendency of any claim for
2 payment made by the provider to the organization for payment
3 of the services and any legal proceedings or
4 dispute-resolution process to determine whether the
5 organization is liable for the services if the provider is
6 informed that such proceedings are taking place. It shall be
7 conclusively presumed that a physician does not know and
8 should not know that an organization is liable unless:
9 (a) The provider is informed by the organization that
10 it accepts liability;
11 (b) A court of competent jurisdiction determines that
12 the organization is liable; or
13 (c) The department or agency makes a final
14 determination that the organization is required to pay for
15 such services subsequent to a recommendation made by the
16 Statewide Provider and Subscriber Assistance Panel pursuant to
17 s. 408.7056.
18 (5) An organization and the department shall report
19 any suspected violation of this section by a health care
20 practitioner to the Department of Health and by a facility to
21 the agency which shall take such actions as authorized by law.
22 Section 3. Section 641.3155, Florida Statutes, is
23 amended to read:
24 641.3155 Provider contracts; Payment of claims.--
25 (1)(a) As used in this section, the term "clean claim"
26 means a claim that has no defect or impropriety, including
27 lack of required substantiating documentation for
28 noncontracting providers and suppliers, or particular
29 circumstances requiring special treatment which prevent timely
30 payment from being made on the claim. A claim may not be
31 considered not clean solely because a health maintenance
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1 organization refers the claim to a medical specialist within
2 the health maintenance organization for examination. If
3 additional substantiating documentation, such as the medical
4 record or encounter data, is required from a source outside
5 the health maintenance organization, the claim is considered
6 not clean.
7 (b) The department shall adopt rules to establish
8 claim forms consistent with federal claim-filing standards for
9 health maintenance organizations required by the federal
10 Health Care Financing Administration. The department may adopt
11 rules relating to coding standards consistent with Medicare
12 coding standards adopted by the federal Health Care Financing
13 Administration.
14 (2)(1)(a) A health maintenance organization shall pay
15 any clean claim or any portion of a clean claim made by a
16 contract provider for services or goods provided under a
17 contract with the health maintenance organization or a clean
18 claim made by a noncontract provider which the organization
19 does not contest or deny within 35 days after receipt of the
20 claim by the health maintenance organization which is mailed
21 or electronically transferred by the provider.
22 (b) A health maintenance organization that denies or
23 contests a provider's claim or any portion of a claim shall
24 notify the contract provider, in writing, within 35 days after
25 receipt of the claim by the health maintenance organization
26 receives the claim that the claim is contested or denied. The
27 notice that the claim is denied or contested must identify the
28 contested portion of the claim and the specific reason for
29 contesting or denying the claim, and, if contested, must may
30 include a request for additional information. If the provider
31 submits health maintenance organization requests additional
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1 information, the provider must shall, within 35 days after
2 receipt of the such request, mail or electronically transfer
3 the information to the health maintenance organization. The
4 health maintenance organization shall pay or deny the claim or
5 portion of the claim within 45 days after receipt of the
6 information.
7 (3)(2) Payment of a claim is considered made on the
8 date the payment was received or electronically transferred or
9 otherwise delivered. An overdue payment of a claim bears
10 simple interest at the rate of 10 percent per year. Interest
11 on an overdue payment for a clean claim or for any uncontested
12 portion of a clean claim begins to accrue on the 36th day
13 after the claim has been received. The interest is payable
14 with the payment of the claim.
15 (4)(3) A health maintenance organization shall pay or
16 deny any claim no later than 120 days after receiving the
17 claim. Failure to do so creates an uncontestable obligation
18 for the health maintenance organization to pay the claim.
19 (5)(a) If, as a result of retroactive review of
20 coverage decisions or payment levels, a health maintenance
21 organization determines that it has made an overpayment to a
22 provider for services rendered to a subscriber, the
23 organization must make a claim for such overpayment. The
24 organization may not reduce payment to that provider for other
25 services unless the provider agrees to the reduction or fails
26 to respond to the organization's claim as required in this
27 subsection.
28 (b) A provider shall pay a claim for an overpayment
29 made by a health maintenance organization which the provider
30 does not contest or deny within 35 days after receipt of the
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1 claim that is mailed or electronically transferred to the
2 provider.
3 (c) A provider that denies or contests an
4 organization's claim for overpayment or any portion of a claim
5 shall notify the organization, in writing, within 35 days
6 after the provider receives the claim that the claim for
7 overpayment is contested or denied. The notice that the claim
8 for overpayment is denied or contested must identify the
9 contested portion of the claim and the specific reason for
10 contesting or denying the claim, and, if contested, must
11 include a request for additional information. If the
12 organization submits additional information, the organization
13 must, within 35 days after receipt of the request, mail or
14 electronically transfer the information to the provider. The
15 provider shall pay or deny the claim for overpayment within 45
16 days after receipt of the information.
17 (d) Payment of a claim for overpayment is considered
18 made on the date payment was received or electronically
19 transferred or otherwise delivered to the organization, or the
20 date that the provider receives a payment from the
21 organization that reduces or deducts the overpayment. An
22 overdue payment of a claim bears simple interest at the rate
23 of 10 percent a year. Interest on an overdue payment of a
24 claim for overpayment or for any uncontested portion of a
25 claim for overpayment begins to accrue on the 36th day after
26 the claim for overpayment has been received.
27 (e) A provider shall pay or deny any claim for
28 overpayment no later than 120 days after receiving the claim.
29 Failure to do so creates an uncontestable obligation for the
30 provider to pay the claim.
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1 (6)(4) Any retroactive reductions of payments or
2 demands for refund of previous overpayments which are due to
3 retroactive review-of-coverage decisions or payment levels
4 must be reconciled to specific claims unless the parties agree
5 to other reconciliation methods and terms. Any retroactive
6 demands by providers for payment due to underpayments or
7 nonpayments for covered services must be reconciled to
8 specific claims unless the parties agree to other
9 reconciliation methods and terms. The look-back period may be
10 specified by the terms of the contract.
11 (7)(a) A provider claim for payment shall be
12 considered received by the health maintenance organization, if
13 the claim has been electronically transmitted to the health
14 maintenance organization, when receipt is verified
15 electronically or, if the claim is mailed to the address
16 disclosed by the organization, on the date indicated on the
17 return receipt. A provider must wait 45 days from receipt of a
18 claim before submitting a duplicate claim.
19 (b) A health maintenance organization claim for
20 overpayment shall be considered received by a provider, if the
21 claim has been electronically transmitted to the provider,
22 when receipt is verified electronically or, if the claim is
23 mailed to the address disclosed by the provider, on the date
24 indicated on the return receipt. An organization must wait 45
25 days from the provider's receipt of a claim for overpayment
26 before submitting a duplicate claim.
27 (8) A provider who bills electronically is entitled to
28 electronic acknowledgement of the receipt of a claim within 72
29 hours.
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1 (9) A health maintenance organization may not
2 retroactively deny a claim more than 1 year after the date of
3 service because of subscriber ineligibility.
4 Section 4. Section 641.3156, Florida Statutes, is
5 created to read:
6 641.3156 Treatment authorization; payment of claims.--
7 (1) A health maintenance organization must pay any
8 hospital-service or referral-service claim for treatment for
9 an eligible subscriber which was authorized by a physician
10 empowered by contract with the health maintenance organization
11 to authorize or direct the patient's utilization of health
12 care services and which was also authorized in accordance with
13 the health maintenance organization's current and communicated
14 procedures, unless the physician provided information to the
15 health maintenance organization with the willful intention to
16 misinform the health maintenance organization.
17 (2) A claim for treatment may not be denied if a
18 provider follows the health maintenance organization's
19 authorization procedures and receives authorization for a
20 covered service for an eligible subscriber, unless the
21 physician provided information to the health maintenance
22 organization with the willful intention to misinform the
23 health maintenance organization.
24 (3) Emergency services are subject to the provisions
25 of s. 641.513 and are not subject to the provisions of this
26 section.
27 Section 5. Subsection (4) of section 641.495, Florida
28 Statutes, is amended to read:
29 641.495 Requirements for issuance and maintenance of
30 certificate.--
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1 (4) The organization shall ensure that the health care
2 services it provides to subscribers, including physician
3 services as required by s. 641.19(13)(d) and (e), are
4 accessible to the subscribers, with reasonable promptness,
5 with respect to geographic location, hours of operation,
6 provision of after-hours service, and staffing patterns within
7 generally accepted industry norms for meeting the projected
8 subscriber needs. The health maintenance organization must
9 have the capability of providing treatment authorization 24
10 hours a day, 7 days a week. Requests for treatment
11 authorization may not be held pending unless the requesting
12 provider contractually agrees to take a pending or tracking
13 number.
14 Section 6. Effective January 1, 2001, section
15 408.7057, Florida Statutes, is created to read:
16 408.7057 Statewide provider and managed care
17 organization claim dispute resolution program.--
18 (1) As used in this section, the term:
19 (a) "Managed care organization" means a health
20 maintenance organization or a prepaid health clinic certified
21 under chapter 641, a prepaid health plan authorized under s.
22 409.912, or an exclusive provider organization certified under
23 s. 627.6472.
24 (b) "Resolution organization" means a qualified
25 independent third-party claims dispute resolution entity
26 selected by and contracted with the Agency for Health Care
27 Administration.
28 (2)(a) The Agency for Health Care Administration shall
29 establish a program to provide assistance to contracting and
30 noncontracting providers and managed care organizations for
31 claim disputes that are not resolved by the provider and the
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1 managed care organization. The program must include the agency
2 contracting with a resolution organization to timely review
3 and consider claims disputes submitted by providers and
4 managed care organizations and to recommend to the agency an
5 appropriate resolution of those disputes. The agency shall
6 establish by rule jurisdictional amounts and methods of
7 aggregation for claims disputes that may be considered by the
8 resolution organization.
9 (b) The resolution organization shall review claim
10 disputes filed by contracting and noncontracting providers and
11 managed care organizations unless the disputed claim:
12 1. Is related to interest payment;
13 2. Does not meet the jurisdictional amounts or the
14 methods of aggregation established by agency rule, as provided
15 in paragraph (a);
16 3. Is part of an internal grievance in a Medicare
17 managed care organization or a reconsideration appeal through
18 the Medicare appeals process;
19 4. Is related to a health plan that is not regulated
20 by the state, such as an administrative services organization,
21 a third-party administrator, or a federal employee health
22 benefit program;
23 5. Is part of a Medicaid fair hearing pursued under 42
24 C.F.R. ss. 431.220 et seq.;
25 6. Is the basis for an action pending in state or
26 federal court;
27 7. Is subject to a binding claims dispute resolution
28 process provided by contract entered into prior to July 1,
29 2000, between the provider and the managed care organization;
30 or
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1 8. Is subject to a binding claims dispute resolution
2 process provided by a contract entered into or renewed on or
3 after July 1, 2000, in which the provider has elected to
4 arbitrate the claim. All contracts entered into after the
5 effective date of this act which provide for a binding claims
6 dispute resolution process shall allow providers the option of
7 pursuing either the contracted dispute resolution process or
8 bringing the claim before the resolution organization created
9 by this section.
10 (3) The agency shall adopt rules to establish a
11 process for the consideration by the resolution organization
12 of claims disputes submitted by either a provider or managed
13 care organization which shall include the issuance by the
14 resolution organization of a written recommendation, supported
15 by findings of fact, to the agency within 60 days after
16 receipt of the claims dispute submission.
17 (4) Within 30 days after receipt of the recommendation
18 of the resolution organization the agency shall issue a final
19 order subject to the provisions of chapter 120.
20 (5) The entity that does not prevail in the agency's
21 order must pay a review cost to the review organization as
22 determined by agency rule, which shall include an
23 apportionment of the review fee in those cases where both
24 parties may prevail in part. The failure of the nonprevailing
25 party to pay the ordered review cost within 35 days after the
26 agency's order will subject the nonpaying party to a penalty
27 of no more than $500 per day until the penalty is paid.
28 (6) The Agency for Health Care Administration may
29 adopt rules necessary to administer this section.
30 Section 7. Paragraph (a) of subsection (2) of section
31 395.1065, Florida Statutes, is amended to read:
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1 395.1065 Criminal and administrative penalties;
2 injunctions; emergency orders; moratorium.--
3 (2)(a) The agency may deny, revoke, or suspend a
4 license or impose an administrative fine, not to exceed $1,000
5 per violation, per day, for the violation of any provision of
6 this part or rules adopted under this part or s. 641.3154
7 promulgated hereunder. Each day of violation constitutes a
8 separate violation and is subject to a separate fine. The
9 agency may impose an administrative fine for the violation of
10 s. 641.3155 in amounts specified in s. 641.52.
11 Section 8. Section 817.50, Florida Statutes, is
12 amended to read:
13 817.50 Fraudulently obtaining goods, services, etc.,
14 from a health care provider hospital.--
15 (1) Whoever shall, willfully and with intent to
16 defraud, obtain or attempt to obtain goods, products,
17 merchandise or services from any health care provider, as
18 "provider" is defined in s. 641.19(15), hospital in this state
19 shall be guilty of a misdemeanor of the second degree,
20 punishable as provided in s. 775.082 or s. 775.083.
21 (2) If any person gives to any provider hospital in
22 this state a false or fictitious name or a false or fictitious
23 address or assigns to any provider hospital the proceeds of
24 any health maintenance contract or insurance contract, then
25 knowing that such contract is no longer in force, is invalid,
26 or is void for any reason, such action shall be prima facie
27 evidence of the intent of such person to defraud the provider
28 such hospital.
29 Section 9. Except as otherwise provided, this act
30 shall take effect October 1, 2000, and shall apply to claims
31 for services rendered after such date and to all requests for
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1 claim-dispute resolution which are submitted by a provider or
2 managed care organization 60 days after the effective date of
3 the contract between the resolution organization and the
4 agency.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS for Senate Bill 1508
3
4 Amends and moves current law relating to provider balance
billing of subscribers, revises current law relating to
5 provider contracts, requires certain contractual disclosures
of addresses and a telephone number, and requires procedures
6 for requesting and granting authorization for utilizing health
care services.
7
Prohibits balance billing during the pendency of a claim
8 submitted by a provider for payment to an HMO. As relates to
balance billing, creates a conclusive presumption, based on
9 the absence of three specified circumstances, that a physician
does not know and should not know that an organization is
10 liable for payment for services rendered to a subscriber.
11 Defines the term "clean claim." Prescribes when a claim may be
considered clean or not clean. Requires the Department of
12 Insurance to adopt rules to establish a claim form and
provides the department with discretionary rulemaking
13 authority for establishing coding standards both of which must
be consistent with certain federal standards. Provides
14 requirements and timeframes for payment of a portion of a
clean claim. Specifies timeframes for: denying and contesting
15 a claim and provides for an uncontestable obligation to pay a
claim, submitting requested information, and submitting
16 duplicate claims. Provides a timeframe for accruing of
interest and payment of an overdue payment of a clean claim or
17 an uncontested portion of a claim.
18 Requires a health maintenance organization to make a claim
for overpayment to a provider based on retroactive review.
19 Prohibits a health maintenance organization from retroactively
reducing payment for other services as adjustment for
20 overpayment, unless the provider agrees or does not respond to
the claim for overpayment. Requires a provider to pay an
21 uncontested claim for overpayment by a health maintenance
organization within a specified timeframe. Provides a
22 procedure and timeframes for a provider to notify a health
maintenance organization that it is denying or contesting a
23 claim for overpayment. Specifies when a provider payment of a
claim for overpayment is to be considered made to a health
24 maintenance organization. Provides for assessment of simple
interest against overdue payment of a claim. Specifies when
25 interest on overdue payments of claims for overpayment begins
to accrue. Specifies a timeframe for a provider to deny or
26 contest a claim for overpayment. Provides a timeframe for a
provider to pay or deny a claim for overpayment and provides
27 an uncontestable obligation for payment of such a claim.
28 Specifies when a provider claim that is electronically
transmitted or mailed is considered received. Specifies when a
29 health maintenance organization claim for overpayment that is
electronically transmitted or mailed is considered received.
30 Requires a provider or health maintenance organization to wait
a specified amount of time before submitting a duplicate
31 claim. Mandates acknowledgment of receipts for electronically
submitted provider claims. Prescribes a timeframe after which
19
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 CS for CS for SB 1508
317-2038-00
1 a health maintenance organization is prohibited from denying a
claim for services provided to an ineligible subscriber.
2 Provides for treatment authorization and payment of claims.
Provides for payment of claims for emergency services
3 treatment. Revises provisions of current law relating to
treatment authorization capabilities.
4
Applies current law relating to criminal and administrative
5 penalties that may be assessed against a hospital or
ambulatory surgical center for regulatory violations of
6 licensure regulations to certain prohibited subscriber billing
practices. Subjects a hospital or ambulatory surgical center
7 to administrative fines that the Agency for Health Care
Administration may assess against health maintenance
8 organizations when a hospital violates certain requirements
relating to payment of claims. Expands the applicability of a
9 current provision of law relating to fraud against hospitals
to health care providers, including hospitals.
10
Excludes from consideration by the claim dispute resolution
11 organization, authorized by the bill to hear claim disputes
between HMOs and providers, those disputes that are subject to
12 a contractually binding claims dispute resolution process that
is provided for in a contract entered into prior to July 1,
13 2000, and excludes those claim disputes that the provider has
elected to arbitrate in accordance with a contract entered
14 into or renewed on or after July 1, 2000. Requires that all
contracts between providers and HMOs entered into after the
15 bill's effective date allow providers the option of either a
contracted dispute resolution process or bringing claims
16 before the resolution organization.
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