Senate Bill sb1484

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    Florida Senate - 2001                                  SB 1484

    By Senators Clary and Campbell





    7-667A-01

  1                      A bill to be entitled

  2         An act relating to health insurance; amending

  3         s. 627.4235, F.S.; providing for payments of

  4         benefits under multiple health insurance

  5         policies regardless of certain timeframes;

  6         amending s. 627.613, F.S.; defining the term

  7         "clean claim" for purposes of health insurance

  8         claims made by a provider under contract with a

  9         health insurer; requiring payment within

10         specified periods; requiring the payment of

11         interest on overdue payments; providing payment

12         procedures; requiring the Department of

13         Insurance to adopt rules prescribing forms;

14         requiring the use of standard code sets;

15         creating s. 627.6135, F.S.; defining the term

16         "emergency medical condition"; prohibiting a

17         health insurer from placing certain

18         requirements or limits on the provision of

19         emergency services; providing for determining

20         whether an emergency medical condition exists;

21         providing requirements for providing emergency

22         care and treatment; amending s. 641.19, F.S.;

23         defining the term "emergency medical condition"

24         for purposes of part I of ch. 641, F.S.,

25         relating to health maintenance organizations;

26         amending s. 641.315, F.S.; providing that a

27         contract is unenforceable to the extent that it

28         conflicts with part I of ch. 641, F.S.;

29         amending s. 641.3155, F.S.; providing

30         procedures for the payment of claims; requiring

31         payment within specified periods; requiring the

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  1         payment of interest on overdue payments;

  2         requiring the coordination of benefits;

  3         amending s. 641.3156, F.S.; specifying that

  4         certain authorizations for service are binding

  5         upon the health maintenance organization;

  6         amending s. 641.495, F.S.; providing

  7         requirements for issuing treatment

  8         authorizations; amending s. 408.7057, F.S.;

  9         redefining the term "managed care

10         organization"; providing requirements for

11         filing a claim dispute with a resolution

12         organization; providing an effective date.

13

14  Be It Enacted by the Legislature of the State of Florida:

15

16         Section 1.  Subsection (2) of section 627.4235, Florida

17  Statutes, is amended to read:

18         627.4235  Coordination of benefits.--

19         (2)  A hospital, medical, or surgical expense policy,

20  health care services plan, or self-insurance plan that

21  provides protection or insurance against hospital, medical, or

22  surgical expenses issued in this state or issued for delivery

23  in this state may contain a provision whereby the insurer may

24  reduce or refuse to pay benefits otherwise payable thereunder

25  solely on account of the existence of similar benefits

26  provided under insurance policies issued by the same or

27  another insurer, health care services plan, or self-insurance

28  plan which provides protection or insurance against hospital,

29  medical, or surgical expenses only if, as a condition of

30  coordinating benefits with another insurer, the insurers

31  together pay 100 percent of the total covered reasonable

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  1  expenses actually incurred of the type of expense within the

  2  benefits described in the policies and presented to the

  3  insurer for payment, regardless of any timeframes for payment

  4  or filing of claims established by any applicable contract.

  5         Section 2.  Section 627.613, Florida Statutes, is

  6  amended to read:

  7         (Substantial rewording of section. See

  8         s. 627.613, F.S., for present text.)

  9         627.613  Time of payment of claims.--

10         (1)(a)  The term "clean claim" for a noninstitutional

11  provider means a properly and accurately completed paper or

12  electronic billing instrument that consists of the HCFA 1500

13  data set, or its successor, with entries stated as mandatory

14  by the United States Secretary of Health and Human Services.

15  Such claim does not involve coordination of benefits for

16  third-party liability or subrogation, as evidenced by the

17  information provided on the claim form related to coordination

18  of benefits.

19         (b)  The term "clean claim" for an institutional

20  provider means a properly and accurately completed paper or

21  electronic billing instrument that consists of the UB-92 data

22  set, or its successor, with entries stated as mandatory by the

23  National Uniform Billing Committee. It does not involve

24  coordination of benefits for third-party liability or

25  subrogation, as evidenced by the information provided on the

26  claim form related to coordination of benefits.

27         (2)(a)  A health insurer shall pay any clean claim or

28  any portion of a clean claim made by a contract provider for

29  services or goods provided under a contract with the health

30  insurer, or a clean claim made by a noncontract provider which

31  the insurer does not contest or deny, within 45 days after

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  1  receipt of the claim by the health insurer which is mailed or

  2  electronically transferred by the provider.

  3         (b)  A health insurer that denies or contests a

  4  provider's claim or any portion of a claim must notify the

  5  provider, in writing, within 45 days after the health insurer

  6  receives the claim that the claim is contested or denied. The

  7  notice that the claim is denied or contested must identify the

  8  contested portion of the claim and the specific reason for

  9  contesting or denying the claim, and, if contested, must

10  include a request for additional information. If the provider

11  submits additional information, the provider must, within 35

12  days after receipt of the request, mail or electronically

13  transfer the information to the health insurer. The health

14  insurer shall pay or deny the claim or portion of the claim

15  within 45 days after receipt of the information.

16         (3)  Payment of a claim is considered made on the date

17  the payment was received, electronically transferred, or

18  otherwise delivered. Interest on an overdue payment for a

19  clean claim, or for any uncontested portion of a clean claim,

20  begins to accrue on the 45th day after the date the claim is

21  received, according to the following schedule:

22         (a)  For a claim that is paid between 45 days and 60

23  days after the date the claim was received by the health

24  maintenance organization, interest accrues at a rate of 10

25  percent per year;

26         (b)  For a claim that is paid between 61 days and 90

27  days after the date the claim was received by the health

28  maintenance organization, interest accrues at a rate of 12

29  percent per year;

30         (c)  For a claim that is paid between 91 days and 120

31  days after the date the claim was received by the health

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  1  maintenance organization, interest accrues at a rate of 15

  2  percent per year; and

  3         (d)  For a claim that is paid more than 120 days after

  4  the date the claim was received by the health maintenance

  5  organization, interest accrues at a rate of 18 percent per

  6  year.

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  8  The interest must be included with the payment of the claim.

  9  Failure to include the interest with payment of the claim is a

10  violation of s. 624.4211.

11         (4)  A health insurer must pay or deny a claim not

12  later than 120 days after receiving the claim. Failure to do

13  so creates an uncontestable obligation for the health insurer

14  to pay the claim to the provider.

15         (5)  If, as a result of retroactive review of a

16  coverage decision or payment level, a health insurer finds

17  that it has made an overpayment to a provider for services

18  rendered to a subscriber, the organization may not reduce

19  payment to that provider for other services.

20         (6)  If the claim has been electronically transmitted

21  to the health insurer, a provider's claim for payment shall be

22  considered received by the health insurer on the date receipt

23  is verified electronically or, if the claim is mailed to the

24  address disclosed by the organization, on the date indicated

25  on the return receipt. A provider may not submit a duplicate

26  claim until 45 days following receipt of a claim.

27         (7)  A provider, or the provider's designee, who bills

28  electronically must be provided with an electronic

29  acknowledgment of the receipt of a claim within 72 hours.

30

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  1         (8)  A health insurer may not retroactively deny a

  2  claim because of subscriber ineligibility more than 1 year

  3  after the date of payment of a clean claim.

  4         (9)  A health insurer may not delay payment on a claim

  5  from a physician, hospital, or other provider while waiting

  6  for the submission of a claim from another physician,

  7  hospital, or other provider for services provided during the

  8  same episode of illness. A health insurer may not deny or

  9  withhold payment on a claim because the insured has not paid a

10  required deductible or copayment.

11         (10)  The department shall adopt rules to establish

12  claim forms that are consistent with federal claim-filing

13  standards required by the United States Secretary of Health

14  and Human Services. The department shall adopt rules to

15  establish coding standards that are consistent with Medicare

16  coding standards adopted by the United States Secretary of

17  Health and Human Services. The coding standards shall apply to

18  both electronic and paper claims.

19         (11)  All providers and payers shall use the standard

20  code sets defined for their area of operation by the United

21  States Secretary of Health and Human Services. Unless

22  otherwise defined by the secretary, the effective date for

23  code changes shall be consistent with those adopted by the

24  Medicare contractor, intermediary or carrier, and must include

25  grace periods established by the contractor.

26         (12)  A provision in a provider contract is void and

27  unenforceable to the extent that it purports to waive or

28  preclude the rights, remedies, or requirements set forth in

29  this part.

30         Section 3.  Section 627.6135, Florida Statutes, is

31  created to read:

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  1         627.6135  Requirements for providing emergency services

  2  and care.--

  3         (1)  As used in this section, the term "emergency

  4  medical condition" means:

  5         (a)  A medical condition manifesting itself by acute

  6  symptoms of sufficient severity, which may include severe

  7  pain, psychiatric disturbances, symptoms of substance abuse,

  8  or other acute symptoms, such that the absence of immediate

  9  medical attention could reasonably be expected to result in

10  any of the following:

11         1.  Serious jeopardy to the health of a patient,

12  including a pregnant woman or a fetus.

13         2.  Serious impairment to bodily functions.

14         3.  Serious dysfunction of any bodily organ or part.

15         (b)  With respect to a pregnant woman:

16         1.  That there is inadequate time to effect safe

17  transfer to another hospital prior to delivery;

18         2.  That a transfer may pose a threat to the health and

19  safety of the patient or fetus; or

20         3.  That there is evidence of the onset and persistence

21  of uterine contractions or rupture of the membranes.

22         (2)  In providing for emergency services and care as a

23  covered service, a health insurer may not:

24         (a)  Require prior authorization for the receipt of

25  prehospital transport or treatment or for emergency services

26  and care.

27         (b)  Indicate that emergencies are covered only if care

28  is secured within a certain period of time.

29         (c)  Use terms such as "life threatening" or "bona

30  fide" to qualify the kind of emergency that is covered.

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  1         (d)  Deny payment based on the subscriber's failure to

  2  notify the health insurer in advance of seeking treatment or

  3  within a certain period after the care is given.

  4         (3)  Prehospital and hospital-based trauma services and

  5  emergency services and care must be provided to an insured as

  6  required under ss. 395.1041, 395.4045, and 401.45.

  7         (4)(a)  When an insured is present at a hospital

  8  seeking emergency services and care, the determination as to

  9  whether an emergency medical condition exists shall be made,

10  for the purposes of treatment, by a physician of the hospital

11  or, to the extent permitted by applicable law, by other

12  appropriate licensed professional hospital personnel under the

13  supervision of the hospital physician. The physician or the

14  appropriate personnel shall indicate in the patient's chart

15  the results of the screening, examination, and evaluation. The

16  health insurer shall compensate the provider for the

17  screening, evaluation, and examination that is reasonably

18  calculated to assist the health care provider in arriving at a

19  determination as to whether the patient's condition is an

20  emergency medical condition. The health insurer shall

21  compensate the provider for emergency services and care. If a

22  determination is made that an emergency medical condition does

23  not exist, payment for services rendered subsequent to that

24  determination is governed by the health insurance policy.

25         (b)1.  If a determination has been made that an

26  emergency medical condition exists and the insured has

27  notified the hospital, or the hospital emergency personnel

28  otherwise have knowledge that the patient is insured under a

29  health plan, the hospital must make a reasonable attempt to

30  notify the subscriber's primary care physician, if known, or

31  the health plan, if the health plan had previously requested

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  1  in writing that the notification be made directly to the

  2  health plan, of the existence of the emergency medical

  3  condition. If the primary care physician is not known, or has

  4  not been contacted, the hospital must:

  5         a.  Notify the health plan as soon as possible; or

  6         b.  Notify the health plan within 24 hours or on the

  7  next business day after admission of the subscriber as an

  8  inpatient to the hospital.

  9         2.  If notification required by this paragraph is not

10  accomplished, the hospital must document its attempts to

11  notify the health insurer of the circumstances that precluded

12  attempts to notify the health insurer. A health insurer may

13  not deny payment for emergency services and care based on a

14  hospital's failure to comply with the notification

15  requirements of this paragraph. This paragraph does not alter

16  any contractual responsibility of an insured to make contact

17  with a health insurer, subsequent to receiving treatment for

18  the emergency medical condition.

19         (c)  If the insured's primary care physician responds

20  to the notification, the hospital physician and the primary

21  care physician may discuss the appropriate care and treatment

22  of the subscriber. The health insurer may have a member of the

23  hospital staff with whom it has a contract participate in the

24  treatment of the insured within the scope of the physician's

25  hospital staff privileges. Notwithstanding any other state

26  law, a hospital may request and collect insurance or financial

27  information from a patient, in accordance with federal law,

28  which is necessary to determine if the patient has health

29  insurance, if emergency services and care are not thereby

30  delayed.

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  1         Section 4.  Paragraph (a) of subsection (7) of section

  2  641.19, Florida Statutes, is amended to read:

  3         641.19  Definitions.--As used in this part, the term:

  4         (7)  "Emergency medical condition" means:

  5         (a)  A medical condition manifesting itself by acute

  6  symptoms of sufficient severity, which may include severe

  7  pain, psychiatric disturbances, symptoms of substance abuse,

  8  or other acute symptoms, such that the absence of immediate

  9  medical attention could reasonably be expected to result in

10  any of the following:

11         1.  Serious jeopardy to the health of a patient,

12  including a pregnant woman or a fetus.

13         2.  Serious impairment to bodily functions.

14         3.  Serious dysfunction of any bodily organ or part.

15         Section 5.  Subsection (10) is added to section

16  641.315, Florida Statutes, to read:

17         641.315  Provider contracts.--

18         (10)  A provision in a provider contract is void and

19  unenforceable to the extent that it purports to waive or

20  preclude the rights, remedies, or requirements set forth in

21  this part.

22         Section 6.  Subsections (1) and (3) of section

23  641.3155, Florida Statutes, are amended, and subsection (11)

24  is added to that section, to read:

25         641.3155  Payment of claims.--

26         (1)(a)  As used in this section, the term "clean claim"

27  for a noninstitutional provider means a claim submitted on a

28  HCFA 1500 for a physician licensed under chapter 458 or

29  chapter 459 or other appropriate form for any other

30  noninstitutional provider which has no defect or impropriety,

31  including lack of required substantiating documentation for

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  1  noncontracted providers and suppliers, or particular

  2  circumstances requiring special treatment which prevent timely

  3  payment from being made on the claim. A claim may not be

  4  considered not clean solely because a health maintenance

  5  organization refers the claim to a medical specialist within

  6  the health maintenance organization for examination. If

  7  additional substantiating documentation, such as the medical

  8  record or encounter data, is required from a source outside

  9  the health maintenance organization, the claim is considered

10  not clean. This definition of "clean claim" is repealed on the

11  effective date of rules adopted by the department which define

12  the term "clean claim."

13         (b)  Absent a written definition that is agreed upon

14  through contract, the term "clean claim" for an institutional

15  claim is a properly and accurately completed paper or

16  electronic billing instrument that consists of the UB-92 data

17  set or its successor with entries stated as mandatory by the

18  National Uniform Billing Committee. Such claim does not

19  involve coordination of benefits for third-party liability or

20  subrogation, as evidenced by the information provided on the

21  claim form related to coordination of benefits.

22         (c)  The department shall adopt rules to establish

23  claim forms consistent with federal claim-filing standards for

24  health maintenance organizations required by the United States

25  Secretary of Health and Human Services federal Health Care

26  Financing Administration. The department may adopt rules

27  relating to coding standards consistent with Medicare coding

28  standards adopted by the United States Secretary of Health and

29  Human Services federal Health Care Financing Administration.

30  The coding standards apply to both electronic and paper

31  claims.

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  1         (d)  All providers and payers shall use the standard

  2  code sets defined for their area of operation by the United

  3  States Secretary of Health and Human Services. Unless

  4  otherwise defined by the secretary, the effective date for

  5  code changes shall be consistent with those adopted by the

  6  Medicare contractor, intermediary or carrier, and include

  7  grace periods established by the contractor.

  8         (3)  Payment of a claim is considered made on the date

  9  the payment was received or electronically transferred or

10  otherwise delivered. An overdue payment of a claim bears

11  simple interest at the rate of 10 percent per year. Interest

12  on an overdue payment for a clean claim or for any uncontested

13  portion of a clean claim begins to accrue on the 36th day

14  after the claim has been received, according to the following

15  schedule:.

16         (a)  For a claim that is paid between 36 days and 60

17  days after the date the claim was received by the health

18  maintenance organization, interest accrues at a rate of 10

19  percent per year;

20         (b)  For a claim that is paid between 61 days and 90

21  days after the date the claim was received by the health

22  maintenance organization, interest accrues at a rate of 12

23  percent per year;

24         (c)  For a claim that is paid between 91 days and 120

25  days after the date the claim was received by the health

26  maintenance organization, interest accrues at a rate of 15

27  percent per year; and

28         (d)  For a claim that is paid more than 120 days after

29  the date the claim was received by the health maintenance

30  organization, interest accrues at a rate of 18 percent per

31  year.

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  1

  2  The interest is payable with the payment of the claim.

  3         (11)(a)  Each policy issued by a health maintenance

  4  organization must contain a provision for coordinating

  5  benefits under the policy with any similar benefits provided

  6  by any other health maintenance organization, group hospital,

  7  medical, or surgical expense policy; any group health care

  8  services plan; any auto medical policy; any governmental

  9  medical expense policy; or any group-type self-insurance plan

10  that provides protection or insurance against hospital,

11  medical, or surgical expenses for the same loss.

12         (b)  A policy issued by a health maintenance

13  organization may contain a provision whereby the health

14  maintenance organization may reduce or refuse to pay benefits

15  otherwise payable under the policy solely due to the existence

16  of similar benefits provided under insurance policies issued

17  by the same or another health maintenance organization,

18  insurer, health care services plan, or self-insurance plan if

19  the similar benefits provide protection or insurance against

20  hospital, medical, or surgical expenses only if, as a

21  condition of coordinating benefits with another insurer, 100

22  percent of the total covered benefits described in the

23  policies and presented for payment are paid, regardless of any

24  timeframes for payment or filing of claims established by any

25  applicable contract.

26         Section 7.  Subsection (4) is added to section

27  641.3156, Florida Statutes, to read:

28         641.3156  Treatment authorization; payment of claims.--

29         (4)  Authorization for a covered service provided by a

30  health maintenance organization's contracted physician for an

31  eligible subscriber is binding upon the health maintenance

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  1  organization, and the health maintenance organization may not

  2  deny payment.

  3         Section 8.  Subsection (4) of section 641.495, Florida

  4  Statutes, is amended to read:

  5         641.495  Requirements for issuance and maintenance of

  6  certificate.--

  7         (4)(a)  The organization shall ensure that the health

  8  care services it provides to subscribers, including physician

  9  services as required by s. 641.19(13)(d) and (e), are

10  accessible to the subscribers, with reasonable promptness,

11  with respect to geographic location, hours of operation,

12  provision of after-hours service, and staffing patterns within

13  generally accepted industry norms for meeting the projected

14  subscriber needs. The health maintenance organization must

15  provide treatment authorization 24 hours a day, 7 days a week.

16  Requests for treatment authorization may not be held pending

17  unless the requesting provider contractually agrees to take a

18  pending or tracking number.

19         (b)  The organization shall ensure that treatment

20  authorizations are provided 24 hours a day, 7 days a week. A

21  request for treatment authorization must be responded to

22  within 2 hours. Failure to respond within 2 hours waives the

23  right of the health maintenance organization to deny the claim

24  for lack of authorization. A request for treatment

25  authorization may not be held pending unless the requesting

26  provider contractually agrees to take a pending or tracking

27  number.

28         Section 9.  Paragraph (a) of subsection (1) and

29  paragraphs (a) and (c) of subsection (2) of section 408.7057,

30  Florida Statutes, are amended to read:

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  1         408.7057  Statewide provider and managed care

  2  organization claim dispute resolution program.--

  3         (1)  As used in this section, the term:

  4         (a)  "Managed care organization" means a health

  5  maintenance organization or a prepaid health clinic certified

  6  under chapter 641, a prepaid health plan authorized under s.

  7  409.912, or an exclusive provider organization certified under

  8  s. 627.6472, or a preferred provider organization.

  9         (2)(a)  The Agency for Health Care Administration shall

10  establish a program by January 1, 2001, to provide assistance

11  to contracted and noncontracted providers and managed care

12  organizations for resolution of claim disputes that are not

13  resolved by the provider and the managed care organization.

14  The agency shall contract with a resolution organizations

15  organization to timely review and consider claim disputes

16  submitted by providers and managed care organizations and

17  recommend to the agency an appropriate resolution of those

18  disputes. The agency shall establish by rule jurisdictional

19  amounts and methods of aggregation for claim disputes that may

20  be considered by the resolution organizations organization.

21         (c)  Contracts entered into or renewed on or after

22  October 1, 2000, may require exhaustion of an internal

23  dispute-resolution process as a prerequisite to the submission

24  of a claim by a provider or health maintenance organization to

25  the resolution organization when the dispute-resolution

26  program becomes effective. However, if the internal

27  dispute-resolution process is not completed within 60 days

28  after the filing of the claim dispute with the health

29  maintenance organization, the provider may file a claim

30  dispute with a resolution organization.

31         Section 10.  This act shall take effect July 1, 2001.

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  1            *****************************************

  2                          SENATE SUMMARY

  3    Revises various provisions governing the payment of
      claims by health insurers and health maintenance
  4    organizations. Revises requirements for paying benefits
      under multiple health insurance policies. Defines the
  5    term "clean claim." Requires that a claim be paid within
      a specified period. Requires payment of interest on
  6    overdue payments. Defines the term "emergency medical
      condition." Prohibits certain limits on the provision of
  7    emergency services. Revises requirements for health
      maintenance organization with respect to treatment
  8    authorizations. (See bill for details.)

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