House Bill hb0235

    Florida House of Representatives - 2001                 HB 235

        By Representative Prieguez






  1                      A bill to be entitled

  2         An act relating to dental service claim adverse

  3         determinations; amending s. 627.419, F.S.;

  4         providing for appeals from certain adverse

  5         determinations; providing procedures; providing

  6         requirements; providing a definition; providing

  7         an effective date.

  8

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

10

11         Section 1.  Subsection (9) is added to section 627.419,

12  Florida Statutes, to read:

13         627.419  Construction of policies.--

14         (9)(a)  With respect to any group or individual insurer

15  covering dental services, each claimant, or provider acting

16  for a claimant, who has had an adverse determination rendered

17  regarding a claim shall be provided an opportunity for an

18  appeal to the insurer's licensed dentist who is responsible

19  for the dentally necessary reviews under the plan or is a

20  member of the plan's peer review group. The appeal may be made

21  by telephone and the insurer's licensed physician shall

22  respond within a reasonable time, not to exceed 15 business

23  days.

24         (b)  Any individual or group insurer offering dental

25  coverage shall ensure that only a dentist licensed under

26  chapter 466, or a dentist with an active, unencumbered license

27  in another state with similar licensing requirements, may

28  render an adverse determination regarding a service provided

29  by a dentist licensed in this state. The insurer shall submit

30  to the treating dentist and the subscriber written

31  notification regarding the organization's adverse

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






    Florida House of Representatives - 2001                 HB 235

    708-116-01






  1  determination within 2 working days after the subscriber or

  2  provider is notified of the adverse determination. The written

  3  notification shall include the criteria or benefits provisions

  4  used in the adverse determination, identify the dentist who

  5  rendered the adverse determination, and be signed by an

  6  authorized representative of the insurer or the dentist who

  7  rendered the adverse determination. The insurer shall include

  8  with the notification of an adverse determination information

  9  concerning the appeal process for adverse determinations.

10         (c)  For purposes of this subsection, "adverse

11  determination" means a determination, made by an insurer which

12  covers dental services, that an admission, availability of

13  care, continued stay, or other health care service has been

14  reviewed and, based upon the information provided, does not

15  meet the insurer's requirements for medical necessity,

16  appropriateness, health care setting, level of care, or

17  effectiveness and coverage for the requested service is

18  therefore denied, reduced, altered, or terminated.

19         Section 2.  This act shall take effect October 1, 2001.

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22                          HOUSE SUMMARY

23
      Provides procedures and requirements for appeals from
24    adverse determinations rendered on dental service claims.
      See bill for details.
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CODING: Words stricken are deletions; words underlined are additions.