Senate Bill 0706c1
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Florida Senate - 2000 CS for SB's 706 & 2234
By the Committee on Banking and Insurance; and Senators
Laurent and Saunders
311-1935A-00
1 A bill to be entitled
2 An act relating to health maintenance
3 organizations; creating s. 408.7057, F.S.;
4 providing for a statewide provider and managed
5 care organization claim dispute mediation
6 program; providing an exemption from open
7 meetings requirements; amending s. 641.315,
8 F.S.; requiring payment for specified services;
9 providing for disclosure and notice; amending
10 s. 641.3155, F.S.; defining the term "clean
11 claim"; revising the procedures for payment of
12 claims submitted by providers; amending s.
13 641.495, F.S.; providing for 24-hour, on-line
14 or telephone service; amending s. 641.3903,
15 F.S.; revising the criteria for what
16 constitutes false statements and entries and
17 unfair claim settlement practices; amending s.
18 641.3909, F.S.; providing for additional fines;
19 amending s. 641.31, F.S.; conforming a
20 statutory cross-reference; providing for
21 rulemaking authority; providing an effective
22 date.
23
24 Be It Enacted by the Legislature of the State of Florida:
25
26 Section 1. Section 408.7057, Florida Statutes, is
27 created to read:
28 408.7057 Statewide provider and managed care
29 organization claim dispute mediation program.--
30 (1) As used in this section, the term:
31
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1 (a) "Managed care entity" means a health maintenance
2 organization or a prepaid health clinic certified under
3 chapter 641, a prepaid health plan authorized under s.
4 409.912, or an exclusive provider organization certified under
5 s. 627.6472.
6 (b) "Panel" means a statewide provider and managed
7 care claim dispute panel selected as provided in subsection
8 (7).
9 (c) "Agency" means the Agency for Health Care
10 Administration.
11 (2) The agency shall adopt and implement a program to
12 provide assistance to contracting and noncontracting providers
13 for those claim disputes that are not resolved by the managed
14 care entity to the satisfaction of the provider, and to
15 provide assistance to managed care entities that seek to
16 recover an alleged overpayment to a provider. The program
17 shall consist of one or more panels that meet as often as
18 necessary to timely review, consider, and hear grievances and
19 recommend to the agency or the department any actions that
20 should be taken concerning individual cases heard by the
21 panel. The panel shall hear every claim dispute filed by
22 providers and every overpayment claim filed by managed care
23 entities, unless the disputed claim:
24 (a) In the aggregate, is for an amount of $5,000 or
25 less for institutional claims or, in the aggregate, $500 or
26 less for physician claims;
27 (b) Is part of an internal grievance in a Medicare
28 managed care entity or a reconsideration appeal through the
29 Medicare appeals process;
30 (c) Is related to a health plan not regulated by the
31 state such as an administrative services organization,
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1 third-party administrator, or federal employee health benefit
2 program;
3 (d) Is part of a Medicaid fair hearing pursued under
4 42 C.F.R. ss. 431.220 et seq.;
5 (e) Is the basis for an action pending in state or
6 federal court;
7 (f) Was filed before the provider or the managed care
8 entity made a good-faith effort to resolve the dispute;
9
10 Failure of the provider, the provider's representative, or the
11 managed care entity or its representative filing the claim
12 dispute resolution to attend the hearing is considered a
13 withdrawal of the request.
14 (3) The agency shall review all requests for claims
15 dispute resolution within 30 days after receipt and make a
16 determination whether the claims dispute shall be heard. Once
17 the agency notifies the panel, the provider, and the managed
18 care entity that a claims dispute resolution will be heard by
19 the panel, the panel shall hear the claims dispute either in
20 the network area or by teleconference no later than 60 days
21 after the date the claims dispute was filed, unless waived by
22 all the parties. The agency shall notify the parties, in
23 writing, by facsimile transmission, or by phone, of the time
24 and place of the hearing. The panel may take testimony under
25 oath, request certified copies of documents, and take similar
26 actions to collect information and documentation that will
27 assist the panel in making findings of fact and a
28 recommendation. The panel shall issue a written
29 recommendation, supported by findings of fact, to the provider
30 and the managed care entity no later than 30 days after
31 hearing the claims dispute. If at the hearing the panel
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1 requests additional documentation or additional records, the
2 time for issuing a recommendation is tolled until the
3 information or documentation requested has been provided to
4 the panel. The proceedings of the panel are not subject to
5 chapter 120.
6 (4) If, upon receiving a proper patient authorization
7 along with a properly filed claims dispute, the agency
8 requests medical records from a health care provider or
9 managed care entity, the health care provider or managed care
10 entity that has custody of the records has 10 working days to
11 provide the records to the agency. Failure to provide
12 requested medical records may result in the imposition of a
13 fine of up to $500.
14 (5) After hearing a claims dispute, the panel shall
15 make a recommendation to the agency which may include specific
16 actions the managed care entity must take to comply with state
17 laws or rules regulating managed care entities and which may
18 include requiring the managed care entity to pay the unpaid
19 portion of any claim not paid by the managed care entity or
20 the provider's billed charges. In the case of a claims dispute
21 filed by a managed care entity seeking to recover an alleged
22 overpayment, the panel's recommendation to the agency may
23 include requiring the provider to refund any of the previous
24 overpayment.
25 (6) No later than 30 days after the issuance of the
26 panel's recommendation, the agency may adopt the panel's
27 recommendation or findings of fact in a final order as
28 provided in chapter 120, which it shall issue to the managed
29 care entity and the provider. The final order may require
30 payment of the unpaid portion of any claim not paid by the
31 entity or the provider's billed charges, which shall bear a
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1 simple interest rate of 10 percent from the 36th day after the
2 date the managed care entity received the claim. In the case
3 of a claims dispute filed by the managed care entity seeking
4 to recover an overpayment, the final order may require payment
5 of any of the amount overpaid. The agency or the department
6 may modify all or part of the panel's recommendation as
7 provided in s. 120.57.
8 (7) The panel shall be composed of eight members,
9 consisting of two medical directors of health maintenance
10 organizations that hold current certificates of authority to
11 operate in the state; a physician licensed pursuant to
12 chapters 458 or 459; a physician licensed under chapter 460; a
13 physician licensed under chapter 461; a member representing a
14 hospital; a member employed by the agency; and a member
15 employed by the department. The Governor or his designee shall
16 appoint the six members of the panel not employed by the
17 agency or the department. The remaining two members of the
18 panel shall be chosen with the mutual agreement of the agency
19 and the department. All members of the panel shall be
20 proficient in coding methodology.
21 (8) Meetings of the panel are open to the public
22 unless the provider or managed care entity who requested the
23 claims dispute resolution or the agency determines that
24 information of a sensitive personal nature which discloses a
25 subscriber's medical treatment or history; information which
26 constitutes a trade secret as defined by s. 812.081; or
27 information relating to internal risk management programs as
28 defined in s. 641.55(5)(c), (6), and (8) may be revealed at
29 the panel meeting, in which case that portion of the meeting
30 during which such sensitive personal information, trade secret
31 information, or internal risk management program information
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1 is discussed is exempt from the provisions of s. 286.011 and
2 s. 24(b), Art. I of the State Constitution. All closed
3 meetings shall be recorded by a certified court reporter.
4 Section 2. Section 641.315, Florida Statutes, is
5 amended to read:
6 641.315 Provider contracts.--
7 (1) Whenever a contract exists between a health
8 maintenance organization and a provider and the organization
9 fails to meet its obligations to pay fees for services already
10 rendered to a subscriber, the health maintenance organization
11 shall be liable for such fee or fees rather than the
12 subscriber; and the contract shall so state.
13 (2) Upon receipt of authorization as required in s.
14 641.495(4), covered medical services ordered by a provider and
15 entered on the patient's medical record or covered medical
16 services ordered by the organization's employee or by an
17 entity contracting with or acting on behalf of the
18 organization for an eligible subscriber are considered to be
19 binding upon the health maintenance organization and payment
20 may not be denied by the organization.
21 (3) Whenever a contract exists between a health
22 maintenance organization and a provider, the organization
23 shall disclose to the provider:
24 (a) The mailing address or electronic address where
25 claims should be sent for processing;
26 (b) The telephone number a provider may call to have
27 questions and concerns regarding claims addressed; and
28 (c) The address of any separate claims processing
29 centers for specific types of services.
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1 An organization shall provide in no less than 30 calendar
2 days, prior written notice of any changes in the information
3 required in this subsection to its contracted providers.
4 (4)(2) No subscriber of an HMO shall be liable to any
5 provider of health care services for any services covered by
6 the HMO.
7 (5)(3) No provider of services or any representative
8 of such provider shall collect or attempt to collect from an
9 HMO subscriber any money for services covered by an HMO and no
10 provider or representative of such provider may maintain any
11 action at law against a subscriber of an HMO to collect money
12 owed to such provider by an HMO.
13 (6)(4) Every contract between an HMO and a provider of
14 health care services shall be in writing and shall contain a
15 provision that the subscriber shall not be liable to the
16 provider for any services covered by the subscriber's contract
17 with the HMO.
18 (7)(5) The provisions of this section shall not be
19 construed to apply to the amount of any deductible or
20 copayment which is not covered by the contract of the HMO.
21 (8)(6)(a) For all provider contracts executed after
22 October 1, 1991, and within 180 days after October 1, 1991,
23 for contracts in existence as of October 1, 1991:
24 1. The contracts must provide that the provider shall
25 provide 60 days' advance written notice to the health
26 maintenance organization and the department before canceling
27 the contract with the health maintenance organization for any
28 reason; and
29 2. The contract must also provide that nonpayment for
30 goods or services rendered by the provider to the health
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1 maintenance organization shall not be a valid reason for
2 avoiding the 60-day advance notice of cancellation.
3 (b) For all provider contracts executed after October
4 1, 1996, and within 180 days after October 1, 1996, for
5 contracts in existence as of October 1, 1996, the contracts
6 must provide that the health maintenance organization will
7 provide 60 days' advance written notice to the provider and
8 the department before canceling, without cause, the contract
9 with the provider, except in a case in which a patient's
10 health is subject to imminent danger or a physician's ability
11 to practice medicine is effectively impaired by an action by
12 the Board of Medicine or other governmental agency.
13 (9)(7) Upon receipt by the health maintenance
14 organization of a 60-day cancellation notice, the health
15 maintenance organization may, if requested by the provider,
16 terminate the contract in less than 60 days if the health
17 maintenance organization is not financially impaired or
18 insolvent.
19 (10)(8) A contract between a health maintenance
20 organization and a provider of health care services shall not
21 contain any provision restricting the provider's ability to
22 communicate information to the provider's patient regarding
23 medical care or treatment options for the patient when the
24 provider deems knowledge of such information by the patient to
25 be in the best interest of the health of the patient.
26 (11)(9) A contract between a health maintenance
27 organization and a provider of health care services may not
28 contain any provision that in any way prohibits or restricts:
29 (a) The health care provider from entering into a
30 commercial contract with any other health maintenance
31 organization; or
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1 (b) The health maintenance organization from entering
2 into a commercial contract with any other health care
3 provider.
4 (12)(10) A health maintenance organization or health
5 care provider may not terminate a contract with a health care
6 provider or health maintenance organization unless the party
7 terminating the contract provides the terminated party with a
8 written reason for the contract termination, which may include
9 termination for business reasons of the terminating party. The
10 reason provided in the notice required in this section or any
11 other information relating to the reason for termination does
12 not create any new administrative or civil action and may not
13 be used as substantive evidence in any such action, but may be
14 used for impeachment purposes. As used in this subsection, the
15 term "health care provider" means a physician licensed under
16 chapter 458, chapter 459, chapter 460, or chapter 461, or a
17 dentist licensed under chapter 466.
18 Section 3. Section 641.3155, Florida Statutes, is
19 amended to read:
20 641.3155 Provider contracts; Payment of claims
21 submitted by providers.--
22 (1)(a) As used in this section, the term "clean claim"
23 means a completed claim, as determined under department rules
24 adopted pursuant to ch. 120, submitted by institutional
25 providers on a UB-92 claim form or by other providers on a
26 HCFA 1500 claim form for medical care or health care services
27 under a health care plan. The department shall use the most
28 recently adopted format adopted by the National Uniform
29 Billing Committee for institutional providers and by the
30 National Uniform Claims Committee for all other providers.
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1 (b) A health maintenance organization shall notify the
2 provider within 14 days after receipt of a claim whether the
3 submitted claim is deficient in any way, whether the patient
4 receiving the service is an eligible subscriber, or if the
5 service is not authorized, if applicable. The failure of a
6 health maintenance organization to provide the provider with
7 such notice constitutes a complete waiver of the health
8 maintenance organization's right to deny any part of the
9 claim. The notification by the organization that the submitted
10 claim is deficient shall toll the 35-day period provided by
11 paragraph (2)(a) until the provider submits the necessary
12 information to the organization to properly complete the
13 claim.
14 (2)(1)(a) A health maintenance organization shall pay
15 any clean claim or any portion of a clean claim made either by
16 a contract provider for services or goods provided under a
17 contract with the health maintenance organization or by a
18 noncontracted provider which the organization does not contest
19 or deny within 35 days after receipt of the clean claim by the
20 health maintenance organization which is mailed or
21 electronically transferred by the provider.
22 (b) A health maintenance organization that denies or
23 contests a provider's clean claim or any portion of a clean
24 claim shall notify the contract provider, in writing, within
25 35 days after receipt of the claim by the health maintenance
26 organization that the claim is contested or denied. The notice
27 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 may include a request for
30 additional information. If the health maintenance organization
31 requests additional information, the provider shall, within 35
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1 days after receipt of such request, mail or electronically
2 transfer the information to the health maintenance
3 organization. The provider may charge the organization the
4 reasonable costs of copying and providing the additional
5 information, including reasonable staff time, as provided in
6 s. 395.3925 and s. 455.667. The health maintenance
7 organization shall pay or deny the claim or portion of the
8 claim within 45 days after receipt of the information.
9 (3) In order for a health maintenance organization to
10 contest a portion of a clean claim, the health maintenance
11 organization must pay the provider the uncontested portion of
12 the claim. The failure to pay the uncontested portion of a
13 claim constitutes a complete waiver of the health maintenance
14 organization's right to deny any part of the claim.
15 (4)(2) Payment of a claim is considered made on the
16 date the payment was received or electronically transferred or
17 otherwise delivered. An overdue payment, either after 35 days
18 for clean, uncontested claims, or after 120 days for all other
19 claims, reverts to the provider's billed charges. The failure
20 of the health maintenance organization to pay the claim in a
21 timely manner constitutes a waiver of the discount agreed to
22 by the provider and the organization. of a claim bears simple
23 interest at the rate of 10 percent per year.
24 (5)(3) A health maintenance organization shall pay or
25 deny any claim no later than 120 days after receiving the
26 original claim.
27 (6) A claim shall be considered received by the health
28 maintenance organization, if the claim has been electronically
29 transmitted to the organization, when receipt is verified
30 electronically or, if the claim is mailed to the address
31 disclosed by the organization pursuant to s. 641.315(3), on
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1 the date indicated on the return receipt. Providers must wait
2 45 days from receipt of a claim before submitting a duplicate
3 claim.
4 (4) Any retroactive reductions of payments or demands
5 for refund of previous overpayments which are due to
6 retroactive review-of-coverage decisions or payment levels
7 must be reconciled to specific claims unless the parties agree
8 to other reconciliation methods and terms. Any retroactive
9 demands by providers for payment due to underpayments or
10 nonpayments for covered services must be reconciled to
11 specific claims unless the parties agree to other
12 reconciliation methods and terms. The look-back period may be
13 specified by the terms of the contract.
14 Section 4. Subsection (4) of section 641.495, Florida
15 Statutes, is amended to read:
16 641.495 Requirements for issuance and maintenance of
17 certificate.--
18 (4) The organization shall ensure that the health care
19 services it provides to subscribers, including physician
20 services as required by s. 641.19(13)(d) and (e), are
21 accessible to the subscribers, with reasonable promptness,
22 with respect to geographic location, hours of operation,
23 provision of after-hours service, and staffing patterns within
24 generally accepted industry norms for meeting the projected
25 subscriber needs. The health maintenance organization shall
26 maintain on-line or telephone services 24 hours, 7-days-per
27 week for purposes of confirming subscriber eligibility and
28 authorization of services. Requests for treatment
29 authorization may not be pended. Each organization shall make
30 available communication to a live person for authorization and
31 information on the coverage status of a person. If prior
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1 authorization is required by the contract between the
2 organization and the provider, each organization shall
3 confirm, by facsimile or electronic transmission, subscriber
4 eligibility and authorization of services within 60 minutes of
5 the initiation of the request.
6 Section 5. Subsections (4) and (5) of section
7 641.3903, Florida Statutes, are amended to read:
8 641.3903 Unfair methods of competition and unfair or
9 deceptive acts or practices defined.--The following are
10 defined as unfair methods of competition and unfair or
11 deceptive acts or practices:
12 (4) FALSE STATEMENTS AND ENTRIES.--
13 (a) Knowingly:
14 1. Filing with any supervisory or other public
15 official,
16 2. Making, publishing, disseminating, or circulating,
17 3. Delivering to any person,
18 4. Placing before the public, or
19 5. Causing, directly or indirectly, to be made,
20 published, disseminated, circulated, or delivered to any
21 person, or place before the public,
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23 any material false statement.
24 (b) Knowingly making any false entry of a material
25 fact in any book, report, or statement of any person.
26 (c) Denying a provider's claim for which an
27 authorization had been obtained pursuant to s. 641.315(2).
28 (5) UNFAIR CLAIM SETTLEMENT PRACTICES.--
29 (a) Attempting to settle claims on the basis of an
30 application or any other material document which was altered
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1 without notice to, or knowledge or consent of, the subscriber
2 or group of subscribers to a health maintenance organization;
3 (b) Making a material misrepresentation to the
4 subscriber or provider for the purpose and with the intent of
5 effecting settlement of claims, loss, or damage under a health
6 maintenance contract on less favorable terms than those
7 provided in, and contemplated by, the contract; or
8 (c) Committing or performing against a provider or
9 subscriber with such frequency as to indicate a general
10 business practice any of the following:
11 1. Failing to adopt and implement claims standards
12 defined in this chapter, including s. 641.3155, for the proper
13 processing, payment, and investigation of claims;
14 2. Misrepresenting pertinent facts or contract
15 provisions relating to coverage at issue;
16 3. Failing to acknowledge and act promptly upon any
17 communications from a subscriber or provider with respect to
18 claims;
19 4. Denying of subscriber's or provider's claims or
20 portions of claims without conducting reasonable
21 investigations based upon available information;
22 5. Failing to affirm or deny coverage of claims upon
23 written request of the subscriber or provider within a
24 reasonable time not to exceed 30 days after a claim or
25 proof-of-loss statements have been completed and documents
26 pertinent to the claim have been requested in a timely manner
27 and received by the health maintenance organization;
28 6. Failing to promptly provide a reasonable
29 explanation in writing to the subscriber of the basis in the
30 health maintenance contract in relation to the facts or
31 applicable law for denial of a claim or for the offer of a
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1 compromise settlement or failing to promptly provide a
2 reasonable explanation in writing to the provider of the basis
3 in the health maintenance contract in relation to the facts or
4 applicable law or, in the case of a contracted provider, the
5 basis in the provision of the provider's contract for denial
6 of a claim or partial payment of a claim;
7 7. Downcoding of a provider's claim without seeking
8 additional information or documentation;
9 8. Takebacks of alleged overpayments through
10 reductions or holdbacks of current payments;
11 9.7. Failing to provide, upon written request of a
12 subscriber, itemized statements verifying that services and
13 supplies were furnished, where such statement is necessary for
14 the submission of other insurance claims covered by individual
15 specified disease or limited benefit policies, provided that
16 the organization may receive from the subscriber a reasonable
17 administrative charge for the cost of preparing such
18 statement; or
19 10.8. Failing to provide any subscriber with services,
20 care, or treatment contracted for pursuant to any health
21 maintenance contract without a reasonable basis to believe
22 that a legitimate defense exists for not providing such
23 services, care, or treatment. To the extent that a national
24 disaster, war, riot, civil insurrection, epidemic, or any
25 other emergency or similar event not within the control of the
26 health maintenance organization results in the inability of
27 the facilities, personnel, or financial resources of the
28 health maintenance organization to provide or arrange for
29 provision of a health service in accordance with requirements
30 of this part, the health maintenance organization is required
31 only to make a good faith effort to provide or arrange for
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1 provision of the service, taking into account the impact of
2 the event. For the purposes of this paragraph, an event is
3 not within the control of the health maintenance organization
4 if the health maintenance organization cannot exercise
5 influence or dominion over its occurrence.
6 Section 6. Section 641.3909, Florida Statutes, is
7 amended to read:
8 641.3909 Cease and desist and penalty orders.--After
9 the hearing provided in s. 641.3907, the department shall
10 enter a final order in accordance with s. 120.569. If it is
11 determined that the person, entity, or health maintenance
12 organization charged has engaged in an unfair or deceptive act
13 or practice or the unlawful operation of a health maintenance
14 organization without a subsisting certificate of authority,
15 the department shall also issue an order requiring the
16 violator to cease and desist from engaging in such method of
17 competition, act, or practice or unlawful operation of a
18 health maintenance organization. Further, if the act or
19 practice constitutes a violation of s. 641.3155, s. 641.3901,
20 or s. 641.3903, the department may, at its discretion, order
21 any one or more of the following:
22 (1) Suspension or revocation of the health maintenance
23 organization's certificate of authority if it knew, or
24 reasonably should have known, it was in violation of this
25 part.
26 (2) If it is determined that the person or entity
27 charged has engaged in the business of operating a health
28 maintenance organization without a certificate of authority,
29 an administrative penalty not to exceed $1,000 for each health
30 maintenance contract offered or effectuated.
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1 (3) Notwithstanding s. 641.25, with respect to any
2 nonwillful violation, a fine of between $750 and $1,000 per
3 violation; with respect to any knowing and willful violation,
4 a fine of between $2,500 and $10,000 per violation. For
5 purposes of this subsection, each claim not paid in accordance
6 with s. 641.3155 constitutes a separate violation.
7 Section 7. Paragraph (d) of subsection 38 of section
8 641.31, Florida Statutes, is amended to read:
9 641.31 Health maintenance contracts.--
10 (38)
11 (d) Notwithstanding the limitations of deductibles and
12 copayment provisions in this part, a point-of-service rider
13 may require the subscriber to pay a reasonable copayment for
14 each visit for services provided by a noncontracted provider
15 chosen at the time of the service. The copayment by the
16 subscriber may either be a specific dollar amount or a
17 percentage of the reimbursable provider charges covered by the
18 contract and must be paid by the subscriber to the
19 noncontracted provider upon receipt of covered services. The
20 point-of-service rider may require that a reasonable annual
21 deductible for the expenses associated with the
22 point-of-service rider be met and may include a lifetime
23 maximum benefit amount. The rider must include the language
24 required by s. 627.6044 and must comply with copayment limits
25 described in s. 627.6471. Section 641.315(4) and (5)
26 641.315(2) and (3) does not apply to a point-of-service rider
27 authorized under this subsection.
28 Section 8. The Agency for Health Care Administration
29 shall adopt rules to administer this act.
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1 Section 9. This act shall take effect July 1, 2000,
2 and shall apply to all claims submitted by a provider to a
3 health maintenance entity after that date.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bills 706 and 2234
3
4 Provides that an HMO is bound by and required to, make payment
for an eligible subscriber upon receipt of authorization as
5 required by s. 641.495(4), (which requires HMO authorization
and confirmation of eligibility within 60 minutes of the
6 request), for covered medical services ordered by a provider
and entered on the patient's medical record or covered medical
7 services ordered by the HMO's employee or by an entity
contracting with or acting on behalf of the HMO.
8
Requires an HMO to notify the provider within 14 days after
9 receipt of a claim whether it is deficient in any way, whether
the patient receiving the service is an eligible subscriber,
10 or if the service is not authorized. Failure to do so
constitutes a complete waiver of the HMO's right to deny any
11 part of the claim.
12 Requests for treatment authorization may not be held pending.
Requires the HMO to confirm, by facsimile or electronically,
13 subscriber eligibility and authorization within 60 minutes of
the request.
14
Requires an HMO to disclose to contract providers the mailing
15 or electronic address where claims should be sent for
processing; the telephone number a provider may call for
16 questions; and the address of any separate claims processing
centers for specific types of services. The HMO must provide
17 written notice to contract providers at least 30 days prior to
any change in this information.
18
Applies the prompt payment statute, s. 641.3155, F.S., to
19 claims by non-contract providers.
20 Applies the requirements of the prompt payment statute (s.
641.3155) to a "clean claim," defined as determined under
21 Department of Insurance rules, submitted by institutional
providers on specified claim forms.
22
Provides that a claim shall be considered received by the HMO,
23 if the claim has been electronically transmitted, when receipt
is verified electronically; or if the claim is mailed to the
24 address disclosed by the HMO, on the date indicated on the
return receipt. Providers must wait 45 days before
25 resubmitting a duplicate claim.
26 Authorizes the Department of Insurance to assess a penalty of
between $750 and $1,000 for each non-willful violation, and
27 between $2,500 and $10,000 for each knowing and willful
violation of ss. 641.3901, 641.3903 (all current and new
28 unfair trade practices), or 641.3155 (prompt payment). Each
claim not paid in accordance with s. 641.3155 shall constitute
29 a separate violation.
30 Prohibits retroactive reduction of previous overpayments
through reduction of current payments, which would be an
31 unfair trade practice subject to department sanctions; and
repeals current s. 641.3155(4) which requires such reductions
19
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 CS for SB's 706 & 2234
311-1935A-00
1 to be reconciled to specific claims.
2 Creates a new Statewide Provider and Managed Care Organization
Claim Dispute Mediation Program, established by the Agency for
3 Health Care Administration to assist contracting and
non-contracting providers and managed care entities to assist
4 providers whose claims are not resolved to their satisfaction
and managed care entities that seek to recover an overpayment.
5
Provisions related to the new claims dispute mediation program
6 contain exemptions from public meetings and public records
laws and constitutional requirements.
7
The committee substitute deletes provisions in SB 2234 that:
8 added definitions for covered services, noncovered services,
and subscriber expenses; required an HMO to notify the
9 provider that a claim had been received within 2 days or 10
days for claims submitted electronically or by mail,
10 respectively; required HMOs to acknowledge receiving requested
additional information for a provider within 5 days after its
11 receipt; authorized the Department of Insurance to impose an
administrative penalty against an HMO of up to $50,000 for
12 certain violations; and required that HMOs ensure that only a
licensed Florida physician may render an adverse determination
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