Senate Bill 0162c2

    Florida Senate - 2000                     CS for CS for SB 162

    By the Committees on Banking and Insurance; Health, Aging and
    Long-Term Care; and Senators Cowin and Kirkpatrick




    311-2004-00

  1                      A bill to be entitled

  2         An act relating to adverse determinations;

  3         amending s. 641.51, F.S., relating to quality

  4         assurance program requirements for certain

  5         managed-care organizations; allowing the

  6         rendering of adverse determinations by

  7         physicians licensed in Florida or states with

  8         similar requirements; requiring the submission

  9         of facts and documentation pertaining to

10         rendered adverse determinations; providing

11         timeframe for organizations to submit facts and

12         documentation to providers and subscribers in

13         writing; requiring an authorized representative

14         to sign the notification; providing an

15         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 (4), (5), (6), (7),

20  (8), (9), and (10) of section 641.51, Florida Statutes, are

21  redesignated as subsections (5), (6), (7), (8), (9), (10), and

22  (11), respectively, and a new subsection (4) is added to that

23  section to read:

24         641.51  Quality assurance program; second medical

25  opinion requirement.--

26         (4)  The organization shall ensure that only a

27  physician licensed under chapter 458 or chapter 459; or an

28  M.D. or D.O. physician with an active, unencumbered license in

29  another state with similar licensing requirements may render

30  an adverse determination regarding a service provided by a

31  physician licensed in this state. The organization shall

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CODING: Words stricken are deletions; words underlined are additions.






    Florida Senate - 2000                     CS for CS for SB 162
    311-2004-00




  1  submit to the treating provider and the subscriber written

  2  notification regarding the organization's adverse

  3  determination within 2 working days after the subscriber or

  4  provider is notified of the adverse determination. The written

  5  notification must include the utilization review criteria or

  6  benefits provisions used in the adverse determination,

  7  identify the physician who rendered the adverse determination,

  8  and be signed by an authorized representative of the

  9  organization or the physician who renders the adverse

10  determination. The organization must include with the

11  notification of an adverse determination information

12  concerning the appeal process for adverse determinations.

13         Section 2.  This act shall take effect July 1, 2000.

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15          STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
                       COMMITTEE SUBSTITUTE FOR
16                          CS for SB 162

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18  Deletes the provisions that amended ss. 458.331 and 459.015,
    F.S., that added grounds for discipline against medical
19  physicians and osteopathic physicians, respectively.

20  Revises the amendments to s. 641.51, F.S., related to adverse
    decisions made by a health maintenance organization, to allow
21  a physician licensed in another state to make such
    determinations, under certain conditions.
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    Revises the information that must be contained in the notice
23  of the adverse decision.

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