CODING: Words stricken are deletions; words underlined are additions.
HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
CHAMBER ACTION
Senate House
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11 The Committee on Judicial Oversight offered the following:
12
13 Substitute Amendment for Amendment (864531) (with title
14 amendment)
15 On page 3, line 9, through page 34, line 2,
16 remove: all of said lines
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18 and insert:
19 Section 1. Section 408.7057, Florida Statutes, is
20 amended to read:
21 408.7057 Statewide provider and managed care
22 organization claim dispute resolution program.--
23 (1) As used in this section, the term:
24 (a) "Managed care organization" means a health
25 maintenance organization or a prepaid health clinic certified
26 under chapter 641, a prepaid health plan authorized under s.
27 409.912, or an exclusive provider organization certified under
28 s. 627.6472, a preferred provider organization under s.
29 627.6471, or a health insurer licensed pursuant to chapter 627
30 transacting group or individual hospital and medical expense
31 incurred health insurance business in this state. This
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 section shall not apply to Medicare supplement, long-term
2 care, disability, limited-benefit, accident-only,
3 hospital-indemnity, specified disease, dental, vision, or
4 other supplemental policies unless said policies provide
5 payment directly to the provider.
6 (b) "Resolution organization" means a qualified
7 independent third-party claim-dispute-resolution entity
8 selected by and contracted with the Agency for Health Care
9 Administration.
10 (c) "Agency" means the Agency for Health Care
11 Administration.
12 (2)(a) The agency for Health Care Administration shall
13 establish a program by January 1, 2001, to provide assistance
14 to contracted and noncontracted providers and managed care
15 organizations for resolution of claim disputes that are not
16 resolved by the provider and the managed care organization.
17 The agency shall contract with a resolution organization to
18 timely review and consider claim disputes submitted by
19 providers and managed care organizations and recommend to the
20 agency an appropriate resolution of those disputes. The agency
21 shall establish by rule jurisdictional amounts and methods of
22 aggregation for claim disputes that may be considered by the
23 resolution organization.
24 (b) The resolution organization shall review claim
25 disputes filed by contracted and noncontracted providers and
26 managed care organizations unless the disputed claim:
27 1. Is related to interest payment;
28 2. Does not meet the jurisdictional amounts or the
29 methods of aggregation established by agency rule, as provided
30 in paragraph (a);
31 3. Is part of an internal grievance in a Medicare
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 managed care organization or a reconsideration appeal through
2 the Medicare appeals process;
3 4. Is related to a health plan that is not regulated
4 by the state;
5 5. Is part of a Medicaid fair hearing pursued under 42
6 C.F.R. ss. 431.220 et seq.;
7 6. Is the basis for an action pending in state or
8 federal court; or
9 7. Is subject to a binding claim-dispute-resolution
10 process provided by contract entered into prior to October 1,
11 2000, between the provider and the managed care organization.
12 (c) Contracts entered into or renewed on or after
13 October 1, 2000, may require exhaustion of an internal
14 dispute-resolution process as a prerequisite to the submission
15 of a claim by a provider or a managed care health maintenance
16 organization to the resolution organization when the
17 dispute-resolution program becomes effective.
18 (d) A contracted or noncontracted provider or managed
19 care health maintenance organization may not file a claim
20 dispute with the resolution organization more than 12 months
21 after a final determination has been made on a claim by a
22 managed care health maintenance organization or provider.
23 (e) The resolution organization shall require the
24 managed care organization or provider submitting the claim
25 dispute to submit any supporting documentation to the
26 resolution organization within 15 days after receipt by the
27 managed care organization or provider of a request from the
28 resolution organization for documentation in support of the
29 claim dispute. The resolution organization may extend the time
30 if appropriate. Failure to submit the supporting documentation
31 within such time period shall result in the dismissal of the
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 submitted claim dispute.
2 (f) The resolution organization shall require the
3 respondent in the claim dispute to submit all documentation in
4 support of its position within 15 days after receiving a
5 request from the resolution organization for supporting
6 documentation. The resolution organization may extend the time
7 if appropriate. Failure to submit the supporting documentation
8 within such time period shall result in a default against the
9 managed care organization or provider. In the event of such a
10 default, the resolution organization shall issue its written
11 recommendation to the agency that a default be entered against
12 the defaulting entity. The written recommendation shall
13 include a recommendation to the agency that the defaulting
14 entity shall pay the entity submitting the claim dispute the
15 full amount of the claim dispute, plus all accrued interest,
16 and shall be considered a nonprevailing party for the purposes
17 of this section.
18 (3) The agency shall adopt rules to establish a
19 process to be used by the resolution organization in
20 considering claim disputes submitted by a provider or managed
21 care organization which must include the issuance by the
22 resolution organization of a written recommendation, supported
23 by findings of fact, to the agency within 60 days after
24 receipt of the claim dispute submission.
25 (4) Within 30 days after receipt of the recommendation
26 of the resolution organization, the agency shall adopt the
27 recommendation as a final order.
28 (5) The agency shall provide written notification
29 within 7 days to the appropriate licensure or certification
30 entity whenever the agency issues a final order pursuant to
31 this section.
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HOUSE AMENDMENT
Bill No. HB 293
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1 (6)(5) The entity that does not prevail in the
2 agency's order must pay a review cost to the review
3 organization, as determined by agency rule. Such rule must
4 provide for an apportionment of the review fee in any case in
5 which both parties prevail in part. If the nonprevailing party
6 fails to pay the ordered review cost within 35 days after the
7 agency's order, the nonpaying party is subject to a penalty of
8 not more than $500 per day until the penalty is paid.
9 (7)(6) The agency for Health Care Administration may
10 adopt rules to administer this section.
11 Section 2. Section 627.613, Florida Statutes, is
12 amended to read:
13 (Substantial rewording of section. See
14 s. 627.613, F.S., for present text.)
15 627.613 Payment of claims.--
16 (1) The contract shall include the following
17 provision:
18
19 "Time of Payment of Claims: After receiving written
20 proof of loss, the insurer will pay monthly all benefits then
21 due for ...(type of benefit).... Benefits for any other loss
22 covered by this policy will be paid as soon as the insurer
23 receives proper written proof."
24
25 (2)(a) As used in this section, the term "clean claim"
26 for a noninstitutional provider means an electronic or
27 nonelectronic claim submitted on a HCFA 1500 form which has no
28 defect or impropriety, including lack of required
29 substantiating documentation for noncontracted providers and
30 suppliers, or particular circumstances requiring special
31 treatment which prevent timely payment from being made on the
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 claim. A claim may not be excluded from meeting this
2 definition solely because a health insurer refers the claim to
3 a medical specialist for examination. If additional
4 substantiating documentation, such as the medical record or
5 encounter data, is required, the claim shall not be considered
6 a clean claim.
7 (b) Absent a written definition that is agreed upon
8 through contract, the term "clean claim" for an institutional
9 claim is a properly and accurately completed paper or
10 electronic billing instrument that consists of the UB-92 data
11 set with entries stated as mandatory by the National Uniform
12 Billing Committee.
13 (c) The department shall adopt rules to establish
14 claim forms consistent with applicable federal claim-filing
15 standards. The department may adopt rules relating to coding
16 standards consistent with Medicare coding standards of the
17 federal Centers for Medicare and Medicaid Services in
18 existence on February 1, 2002.
19 (3) All claims for payment, notices, and requests for
20 more information or review, whether electronic or
21 nonelectronic, are considered received on the date the claim,
22 notice, or request is received.
23 (4) For an electronically submitted claim, a health
24 insurer shall:
25 (a) Provide electronic acknowledgment of the receipt
26 of the claim within 24 hours of receipt of the claim to the
27 provider, or the provider's designee.
28 (b)1. Notify a provider if a claim is "not clean"
29 within 10 days of receipt of the claim.
30 2. A claim determined to be clean during the initial
31 10 days after the health insurer's receipt of the claim must
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 be paid, denied, or contested within 20 days of the receipt of
2 the claim.
3 (c)1. Notification of the health insurer's
4 determination of a "not clean" claim must be accompanied by a
5 complete itemized list of additional information or documents
6 needed to process the claim as a "clean claim." Failure to
7 notify a provider within 20 days of receipt of the claim
8 creates an uncontestable obligation to pay the claim.
9 2. A provider must submit the additional information
10 or documentation, as specified on the complete itemized list,
11 within 15 days of receipt of the notification. Failure of a
12 provider to submit the additional information or documentation
13 requested within 15 days of receipt of the notification may
14 result in denial of the claim.
15 3. Upon receipt of the requested additional
16 information by the health insurer, the health insurer must
17 determine if the claim is clean or not clean. A clean claim
18 must be paid, denied, or contested within 10 days of receipt
19 of the additional information.
20 (d) For purposes of this subsection, electronic means
21 of transmission of claims, notices, documents, and forms shall
22 be used to the greatest extent possible by the health insurer
23 and the provider.
24 (e) A claim determined to be clean but contested must
25 be paid or denied within 120 days of receipt of the claim.
26 Failure to pay or deny a claim within 120 days of receipt of
27 the claim creates an uncontestable obligation to pay the
28 claim.
29 (5) For all nonelectronically submitted claims, a
30 health insurer shall:
31 (a) Provide acknowledgement of receipt of the claim
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 within 15 days of receipt of the claim to the provider, or the
2 provider's designee.
3 (b)1. Notify a provider if a claim is "not clean"
4 within 20 days of receipt.
5 2. A claim determined to be clean during the initial
6 20 days after the health insurer's receipt of the claim must
7 be paid, denied, or contested within 55 days of the receipt of
8 the claim.
9 (c)1. Notification of the health insurer's
10 determination of a "not clean" claim must be accompanied by a
11 complete itemized list of additional information or documents
12 needed to process the claim as a "clean claim." Failure to
13 notify a provider or a provider's designee within 40 days of
14 receipt of the claim that the claim is not clean or to provide
15 a complete itemized list of additional information or
16 documents needed to process the claim creates an uncontestable
17 obligation to pay the claim.
18 2. A provider must submit the additional information
19 or documentation, as specified on the complete itemized list,
20 within 15 days of receipt of the notification. Failure of a
21 provider to submit the additional information or documentation
22 requested within 15 days of receipt of the notification may
23 result in the denial of the claim.
24 3. Upon receipt of the requested additional
25 information by the health insurer, the health insurer must
26 determine if the claim is clean or not clean. A clean claim
27 must be paid, denied, or contested within 20 days of receipt
28 of the additional information.
29 (d) A claim determined to be clean but contested must
30 be paid or denied within 150 days of receipt of the claim.
31 Failure to pay or deny a claim within 150 days of receipt of
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 the claim creates an uncontestable obligation to pay the
2 claim.
3 (6) Payment of a claim is considered made on the date
4 the payment was received or electronically transferred. An
5 overdue payment of a claim bears simple interest of 12 percent
6 per year. Interest on an overdue payment for a clean claim or
7 for any portion of a clean claim begins to accrue on the 36th
8 day after the receipt of a clean electronic claim and on the
9 56th day after receipt of a clean nonelectronic claim. The
10 interest is payable with the payment of the claim.
11 (7) If a health insurer determines that it has made an
12 overpayment to a provider for services rendered to an insured,
13 the health insurer must make a claim for such overpayment. A
14 health insurer that makes a claim for overpayment to a
15 provider under this section shall give the provider a written
16 or electronic statement specifying the basis for the
17 retroactive denial and identifying the claim or claims, or
18 portion thereof, which are being retroactively denied.
19 (a) If an overpayment determination is the result of
20 retroactive review or audit of coverage decisions or payment
21 levels not related to fraud, a health insurer shall adhere to
22 the following procedures:
23 1. All claims for overpayment must be submitted to a
24 provider within 30 months after the health insurer's payment
25 of the claim. A provider must pay, deny, or contest the health
26 insurer's claim for overpayment. All claims for overpayment
27 which are not contested must be paid or denied within 45 days
28 of the receipt of the claim. All contested claims for
29 overpayment must be paid or denied within 120 days of receipt
30 of the claim.
31 2. A provider must notify a health insurer that it
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 will pay, deny, or contest a claim for overpayment within 20
2 days of receipt of the overpayment claim. The provider's
3 notice of contestment must contain a complete itemized list of
4 requested information and documents. Failure of a provider to
5 pay, deny, or contest a claim within the 20 days creates an
6 uncontestable obligation of the provider to pay the
7 overpayment claim.
8 3. A health insurer must respond to a provider's
9 contestment of a claim or request for additional information
10 regarding the claim within 15 days. Failure of a health
11 insurer to respond to a provider's contestment of claim or
12 request for additional information regarding the claim within
13 15 days after receipt of such notice creates an uncontestable
14 denial of the claim.
15 4. The health insurer may not reduce payment to the
16 provider for other services unless the provider agrees to the
17 reduction in writing or fails to respond to the health
18 insurer's claim as required by this paragraph.
19 5. Payment of an overpayment claim is considered made
20 on the date the payment was received or electronically
21 transferred. An overdue payment of a claim bears simple
22 interest at the rate of 12 percent per year. Interest on an
23 overdue payment for a noncontested overpayment payment of a
24 claim begins on the 36th day after receipt of a claim of
25 overpayment. Interest on an overdue payment of a contested
26 overpayment of a claim begins on the 120th day after receipt
27 of a claim for overpayment.
28 (b) A claim for overpayment shall not be permitted
29 beyond 30 months after the health insurer's payment of a claim
30 except that claims for overpayment may be sought beyond that
31 time from providers convicted of fraud pursuant to s. 817.234.
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 (8)(a) For all contracts entered into or renewed on or
2 after October 1, 2002, a health insurer's internal dispute
3 resolution process related to a denied claim not under active
4 review by a mediator, arbitrator, or third-party dispute
5 entity within 60 days, must be finalized within 60 days of the
6 receipt of the provider's request for review or appeal.
7 (b) All claims to a health insurer begun after October
8 1, 2000, not under active review by a mediator, arbitrator, or
9 third-party dispute entity, shall result in a final decision
10 on the claim by the health insurer by January 2, 2003, for the
11 purpose of the statewide provider and managed care
12 organization claim dispute resolution program pursuant to s.
13 408.7057.
14 (9) A provider or any representative of a provider,
15 regardless of whether the provider is under contract with the
16 health insurer, may not collect or attempt to collect money
17 from, maintain any action at law against, or report to a
18 credit agency an insured for payment of covered services for
19 which the health insurer contested or denied the provider's
20 claim for not being a clean claim. The prohibition applies
21 during the pendency of any claim for payment made by the
22 provider to the health insurer for payment of the services or
23 internal dispute resolution process to determine whether the
24 claim is a clean claim and the health insurer is liable for
25 the services. For an electronic claim, this pendency applies
26 from the date the claim is determined to be "not clean" or
27 denied, to the date of the completion of the health insurer's
28 internal dispute resolution process, not to exceed 180 days.
29 For a nonelectronic claim, this pendency applies from the date
30 the claim is determined to be "not clean" or denied, to the
31 date of the completion of the health insurer's internal
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 dispute resolution process, not to exceed 210 days.
2 (10) Any entity which contracts with a health insurer
3 or its designee to furnish provider services to an insured
4 shall comply with the provisions of this section. For the
5 purposes of regulation by the Department of Insurance, a
6 health insurer shall be liable for those entities' compliance,
7 except for those providers or provider-owned or
8 provider-formed entities under contract with a health insurer.
9 (11) This section does not preclude the health insurer
10 and provider from agreeing to other methods of submission and
11 receipt of claims; however, time frames specified herein shall
12 not be extended.
13 (12) A health insurer may not retroactively deny a
14 claim because of insured ineligibility more than 1 year after
15 the date of payment of the claim.
16 (13) A health insurer shall pay a contracted primary
17 care or admitting physician, pursuant to such physician's
18 contract, for providing inpatient services in a contracted
19 hospital to an insured, if such services are determined by the
20 health insurer to be medically necessary and covered services
21 under the health insurer's contract with the contract holder.
22 (14) Upon written notification by an insured, an
23 insurer shall investigate any claim of improper billing by a
24 physician, hospital, or other health care provider. The
25 insurer shall determine if the insured was properly billed for
26 only those procedures and services that the insured actually
27 received. If the insurer determines that the insured has been
28 improperly billed, the insurer shall notify the insured and
29 the provider of its findings and shall reduce the amount of
30 payment to the provider by the amount determined to be
31 improperly billed. If a reduction is made due to such
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 notification by the insured, the insurer shall pay to the
2 insured 20 percent of the amount of the reduction up to $500.
3 (15)(a) Without regard to any other remedy or relief
4 to which a person is entitled, or obligated to under contract,
5 anyone aggrieved by a violation of this section may bring an
6 action to obtain a declaratory judgment that an act or
7 practice violates this section and to enjoin a person who has
8 violated, is violating, or is otherwise likely to violate this
9 section.
10 (b) Except as provided in paragraph (d), in any action
11 brought by a person who has suffered a loss as a result of a
12 violation of this section, such person may recover any amounts
13 due the person under this section, including accrued interest,
14 plus attorney's fees and court costs as provided in paragraph
15 (c).
16 (c) In any civil litigation resulting from either an
17 insured, or the insured's assignee, or health insurer not
18 receiving a payment or repayment of monies due under this
19 section where the losing party is found not to have paid the
20 prevailing party in accordance with this section, the
21 prevailing party, after judgment in the trial court and after
22 exhausting all appeals, if any, shall receive his or her
23 attorney's fees and costs from the losing party; provided,
24 however, that such fees shall not exceed two times the amount
25 in controversy or $5,000, whichever is greater.
26 (d) In any civil litigation brought by a person who
27 has suffered a loss as a result of a violation of this
28 section, if the prevailing party can demonstrate that:
29 1. The acts giving rise to a violation of this section
30 occur with such frequency as to indicate a general business
31 practice; and
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Bill No. HB 293
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1 2. The losing party has failed to exercise good faith
2 in complying with this section, when, under the circumstances,
3 it could and should have done so, had it acted fairly and
4 honestly toward the prevailing party;
5
6 the prevailing party, after judgment in trial court and after
7 exhausting all appeals, if any, shall be entitled to recover
8 up to two times the amount due the person under this section
9 and his or her attorney's fees from the losing party.
10 (e) The attorney for the prevailing party shall submit
11 a sworn affidavit of his or her time spent on the case and his
12 or her costs incurred for all the motions, hearings, and
13 appeals to the trial court.
14 (f) Any award of attorney's fees or costs shall become
15 a part of the judgment and subject to execution as the law
16 allows.
17 (16)(a) The provisions of this section shall also
18 apply to ss. 627.6471 and 627.6472.
19 (b) An insured's assignee who has a contract pursuant
20 to s. 627.6471 or s. 627.6472 with the insurer must include on
21 the claim form the amount due according to the terms of the
22 contract.
23 (17) This section shall only apply to policies and
24 certificates issued or renewed on or after the effective date
25 of this act for group or individual hospital and medical
26 expense-incurred health insurance business in this state.
27 This section shall not apply to Medicare supplement, long-term
28 care, disability, limited-benefit, accident-only, hospital
29 indemnity, special disease, dental, vision, or other
30 supplemental policies unless said policies provide payment
31 directly to the provider.
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Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 Section 3. Section 627.6135, Florida Statutes, is
2 created to read:
3 627.6135 Treatment authorization; payment of claims.--
4 (1) A health insurer must pay any hospital-service or
5 referral-service claim for treatment for an eligible insured
6 which was authorized by a provider empowered by contract to
7 authorize or direct the insured's utilization of health care
8 services and which was also authorized in accordance with the
9 health insured's current and communicated procedures, unless
10 the provider provided information to the health insurer with
11 the willful intention to misinform the health insurer. For
12 purposes of this section, "authorization" consists of any
13 requirement of a provider to obtain prior approval or to
14 provide documentation relating to the necessity of a covered
15 medical treatment or service as a condition for reimbursement
16 for the treatment or service prior to the treatment or
17 service. Each authorization request from a provider must be
18 assigned an identification number by the health insurer.
19 (2) Upon receipt of a request from a provider for
20 authorization, the health insurer shall make a determination
21 within a reasonable time appropriate to medical circumstance
22 indicating whether the treatment or services are authorized.
23 For urgent care requests for which the standard time frame for
24 the health insurer to make a determination would seriously
25 jeopardize the life or health of an insured or would
26 jeopardize the insured's ability to regain maximum function, a
27 health insurer must notify the provider as to its
28 determination as soon as possible taking into account medical
29 exigencies but not later than 72 hours after receiving the
30 request for authorization.
31 (3) Each response to an authorization request must be
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Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 assigned an identification number. Each authorization provided
2 by a health insurer must include the date of request of
3 authorization, the time frame of the authorization, the
4 identification number of the authorization, place of service,
5 type of service, and patient status.
6 (4) Failure of a health insurer to respond to a
7 request for authorization within the specified time frames
8 creates an uncontestable obligation to provide reimbursement
9 for the requested treatment or service.
10 (5) A claim for treatment may not be denied if a
11 provider follows the health insurer's authorization procedures
12 and receives authorization for a covered service for an
13 eligible insured, unless the provider provided information to
14 the health insurer with the willful intention to misinform the
15 health insurer.
16 (6) A health insurer's material change in
17 authorization procedures or requirements for authorization for
18 medical treatment or services must be provided, at least 30
19 days in advance of the change, to all contracted providers and
20 to all noncontracted providers upon request. A health insurer
21 that makes such procedures accessible to providers and
22 insureds electronically, at least 30 days in advance of the
23 change, shall be deemed to be in compliance with this section.
24 An organization shall send notice to a contracted provider
25 providing notice and an effective date of the material
26 changes.
27 Section 4. Subsection (4) of section 627.651, Florida
28 Statutes, is amended to read:
29 627.651 Group contracts and plans of self-insurance
30 must meet group requirements.--
31 (4) This section does not apply to any plan which is
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 established or maintained by an individual employer in
2 accordance with the Employee Retirement Income Security Act of
3 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
4 arrangement as defined in s. 624.437(1), except that a
5 multiple-employer welfare arrangement shall comply with ss.
6 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612,
7 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(8)(6).
8 This subsection does not allow an authorized insurer to issue
9 a group health insurance policy or certificate which does not
10 comply with this part.
11 Section 5. Section 627.662, Florida Statutes, is
12 amended to read:
13 627.662 Other provisions applicable.--The following
14 provisions apply to group health insurance, blanket health
15 insurance, and franchise health insurance:
16 (1) Section 627.569, relating to use of dividends,
17 refunds, rate reductions, commissions, and service fees.
18 (2) Section 627.602(1)(f) and (2), relating to
19 identification numbers and statement of deductible provisions.
20 (3) Section 627.635, relating to excess insurance.
21 (4) Section 627.638, relating to direct payment for
22 hospital or medical services.
23 (5) Section 627.640, relating to filing and
24 classification of rates.
25 (6) Section 627.613, relating to payment of claims.
26 (7) Section 627.6135, relating to treatment
27 authorizations; payment of claims.
28 (8)(6) Section 627.645(1), relating to denial of
29 claims.
30 (9)(7) Section 627.613, relating to time of payment of
31 claims.
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 (10)(8) Section 627.6471, relating to preferred
2 provider organizations.
3 (11)(9) Section 627.6472, relating to exclusive
4 provider organizations.
5 (12)(10) Section 627.6473, relating to combined
6 preferred provider and exclusive provider policies.
7 (13)(11) Section 627.6474, relating to provider
8 contracts.
9 Section 6. Section 641.234, Florida Statutes, is
10 amended to read:
11 641.234 Administrative, provider, and management
12 contracts.--
13 (1) The department may require a health maintenance
14 organization to submit any contract for administrative
15 services, contract with a provider other than an individual
16 physician, contract for management services, and contract with
17 an affiliated entity to the department.
18 (2) After review of a contract the department may
19 order the health maintenance organization to cancel the
20 contract in accordance with the terms of the contract and
21 applicable law if it determines:
22 (a) That the fees to be paid by the health maintenance
23 organization under the contract are so unreasonably high as
24 compared with similar contracts entered into by the health
25 maintenance organization or as compared with similar contracts
26 entered into by other health maintenance organizations in
27 similar circumstances that the contract is detrimental to the
28 subscribers, stockholders, investors, or creditors of the
29 health maintenance organization; or
30 (b) That the contract is with an entity that is not
31 licensed under state statutes, if such license is required, or
18
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 is not in good standing with the applicable regulatory agency.
2 (3) No contract for administrative services,
3 management services, and provider services entered into or
4 renewed by a health maintenance organization may transfer or
5 assign any of the primary risk-taker duties and
6 responsibilities to any other entity, including payment of
7 claims pursuant to s. 641.3155 and quality assurance
8 requirements pursuant to s. 641.51.
9 (4)(3) All contracts for administrative services,
10 management services, provider services other than individual
11 physician contracts, and with affiliated entities entered into
12 or renewed by a health maintenance organization on or after
13 October 1, 1988, shall contain a provision that the contract
14 shall be canceled upon issuance of an order by the department
15 pursuant to this section.
16 Section 7. Subsection (1) of section 641.30, Florida
17 Statutes, is amended to read:
18 641.30 Construction and relationship to other laws.--
19 (1) Every health maintenance organization shall accept
20 the standard health claim form prescribed pursuant to s.
21 641.3155 s. 627.647.
22 Section 8. Subsection (4) of section 641.3154, Florida
23 Statutes, is amended to read:
24 641.3154 Organization liability; provider billing
25 prohibited.--
26 (4) A provider or any representative of a provider,
27 regardless of whether the provider is under contract with the
28 health maintenance organization, may not collect or attempt to
29 collect money from, maintain any action at law against, or
30 report to a credit agency a subscriber of an organization for
31 payment of services for which the organization is liable, if
19
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 the provider in good faith knows or should know that the
2 organization is liable. This prohibition applies during the
3 pendency of any claim for payment made by the provider to the
4 organization for payment of the services and any legal
5 proceedings or dispute resolution process to determine whether
6 the organization is liable for the services if the provider is
7 informed that such proceedings are taking place. It is
8 presumed that a provider does not know and should not know
9 that an organization is liable unless:
10 (a) The provider is informed by the organization that
11 it accepts liability;
12 (b) A court of competent jurisdiction determines that
13 the organization is liable; or
14 (c) The department or agency makes a final
15 determination that the organization is required to pay for
16 such services subsequent to a recommendation made by the
17 Statewide Provider and Subscriber Assistance Panel pursuant to
18 s. 408.7056.
19 (d) The agency issues a final order that the
20 organization is required to pay for such services subsequent
21 to a recommendation made by a resolution organization pursuant
22 to s. 408.7057.
23 Section 9. Section 641.3155, Florida Statutes, is
24 amended to read:
25 (Substantial rewording of section. See
26 s. 641.3155, F.S., for present text.)
27 641.3155 Prompt payment of claims.--
28 (1)(a) As used in this section, the term "clean claim"
29 for a noninstitutional provider means an electronic or
30 nonelectronic claim submitted on a HCFA 1500 form which has no
31 defect or impropriety, including lack of required
20
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 substantiating documentation for noncontracted providers and
2 suppliers, or particular circumstances requiring special
3 treatment which prevent timely payment from being made on the
4 claim. A claim may not be excluded from meeting this
5 definition solely because a health maintenance organization
6 refers the claim to a medical specialist within the health
7 maintenance organization for examination. If additional
8 substantiating documentation, such as the medical record or
9 encounter data, is required from a source outside the health
10 maintenance organization, the claim shall not be considered a
11 clean claim. This definition of "clean claim" is repealed on
12 the effective date of rules adopted by the department which
13 define the term "clean claim".
14 (b) Absent a written definition that is agreed upon
15 through contract, the term "clean claim" for an institutional
16 claim is a properly and accurately completed paper or
17 electronic billing instrument that consists of the UB-92 data
18 set or its successor with entries stated as mandatory by the
19 National Uniform Billing Committee.
20 (c) The department shall adopt rules to establish
21 claim forms consistent with federal claim-filing standards for
22 health maintenance organizations required by the federal
23 Centers for Medicare and Medicaid Services. The department may
24 adopt rules relating to coding standards consistent with
25 Medicare coding standards adopted by the federal Centers for
26 Medicare and Medicaid Services.
27 (2) All claims for payment, notices, and requests for
28 more information or review, whether electronic or
29 nonelectronic, are considered received on the date the claim,
30 notice, or request is received.
31 (3) For an electronically submitted claim, a health
21
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 maintenance organization shall:
2 (a) Provide electronic acknowledgment of the receipt
3 of the claim within 24 hours of receipt of the claim to the
4 provider, or the provider's designee.
5 (b)1. Notify a provider if a claim is "not clean"
6 within 10 days of receipt of the claim.
7 2. A claim determined to be clean during the initial
8 10 days after the organization's receipt of the claim must be
9 paid, denied, or contested within 20 days of the receipt of
10 the claim.
11 (c)1. Notification of the organization's determination
12 of a "not clean" claim must be accompanied by a complete
13 itemized list of additional information or documents needed to
14 process the claim as a "clean claim." Failure to notify a
15 provider within 20 days of receipt of the claim creates an
16 uncontestable obligation to pay the claim.
17 2. A provider must submit the additional information
18 or documentation, as specified on the complete itemized list,
19 within 15 days of receipt of the notification. Failure of a
20 provider to submit the additional information or documentation
21 requested within 15 days of receipt of the notification may
22 result in denial of the claim.
23 3. Upon receipt of the requested additional
24 information by the organization, the organization must
25 determine if the claim is clean or not clean. A clean claim
26 must be paid, denied, or contested within 10 days of receipt
27 of the additional information.
28 (d) For purposes of this subsection, electronic means
29 of transmission of claims, notices, documents, and forms shall
30 be used to the greatest extent possible by the health
31 maintenance organization and the provider.
22
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 (e) A claim determined to be clean but contested must
2 be paid or denied within 120 days of receipt of the claim.
3 Failure to pay or deny a claim within 120 days of receipt of
4 the claim creates an uncontestable obligation to pay the
5 claim.
6 (4) For all nonelectronically submitted claims, a
7 health maintenance organization shall:
8 (a) Provide acknowledgement of receipt of the claim
9 within 15 days of receipt of the claim to the provider, or the
10 provider's designee.
11 (b)1. Notify a provider if a claim is "not clean"
12 within 20 days of receipt.
13 2. A claim determined to be clean during the initial
14 20 days after the organization's receipt of the claim must be
15 paid, denied, or contested within 55 days of the receipt of
16 the claim.
17 (c)1. Notification of the organization's determination
18 of a "not clean" claim must be accompanied by a complete
19 itemized list of additional information or documents needed to
20 process the claim as a "clean claim." Failure to notify a
21 provider or a provider's designee within 40 days of receipt of
22 the claim that the claim is not clean or to provide a complete
23 itemized list of additional information or documents needed to
24 process the claim creates an uncontestable obligation to pay
25 the claim.
26 2. A provider must submit the additional information
27 or documentation, as specified on the complete itemized list,
28 within 15 days of receipt of the notification. Failure of a
29 provider to submit the additional information or documentation
30 requested within 15 days of receipt of the notification may
31 result in the denial of the claim.
23
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 3. Upon receipt of the requested additional
2 information by the organization, the organization must
3 determine if the claim is clean or not clean. A clean claim
4 must be paid, denied, or contested within 20 days of receipt
5 of the additional information.
6 (d) A claim determined to be clean but contested must
7 be paid or denied within 150 days of receipt of the claim.
8 Failure to pay or deny a claim within 150 days of receipt of
9 the claim creates an uncontestable obligation to pay the
10 claim.
11 (5) Payment of a claim is considered made on the date
12 the payment was received or electronically transferred. An
13 overdue payment of a claim bears simple interest of 12 percent
14 per year. Interest on an overdue payment for a clean claim or
15 for any portion of a clean claim begins to accrue on the 36th
16 day after the receipt of a clean electronic claim and on the
17 56th day after receipt of a clean nonelectronic claim. The
18 interest is payable with the payment of the claim.
19 (6) If a health maintenance organization determines
20 that it has made an overpayment to a provider for services
21 rendered to a subscriber, the organization must make a claim
22 for such overpayment. A health maintenance organization that
23 makes a claim for overpayment to a provider under this section
24 shall give the provider a written or electronic statement
25 specifying the basis for the retroactive denial and
26 identifying the claim or claims, or portion thereof, which are
27 being retroactively denied.
28 (a) If an overpayment determination is the result of
29 retroactive review or audit of coverage decisions or payment
30 levels not related to fraud, an organization shall adhere to
31 the following procedures:
24
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 1. All claims for overpayment must be submitted to a
2 provider within 30 months after the organization's payment of
3 the claim. A provider must pay, deny, or contest the health
4 maintenance organization's claim for overpayment. All claims
5 for overpayment which are not contested must be paid or denied
6 within 45 days of the receipt of the claim. All contested
7 claims for overpayment must be paid or denied within 120 days
8 of receipt of the claim.
9 2. A provider must notify a health maintenance
10 organization that it will pay, deny, or contest a claim for
11 overpayment within 20 days of receipt of the overpayment
12 claim. The provider's notice of contestment must contain a
13 complete itemized list of requested information and documents.
14 Failure of a provider to pay, deny, or contest a claim within
15 the 20 days creates an uncontestable obligation of the
16 provider to pay the overpayment claim.
17 3. A health maintenance organization must respond to a
18 provider's contestment of a claim or request for additional
19 information regarding the claim within 15 days. Failure of a
20 health maintenance organization to respond to a provider's
21 contestment of claim or request for additional information
22 regarding the claim within 15 days after receipt of such
23 notice creates an uncontestable denial of the claim.
24 4. The health maintenance organization may not reduce
25 payment to the provider for other services unless the provider
26 agrees to the reduction in writing or fails to respond to the
27 health maintenance organization's claim as required by this
28 paragraph.
29 5. Payment of an overpayment claim is considered made
30 on the date the payment was received or electronically
31 transferred. An overdue payment of a claim bears simple
25
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 interest at the rate of 12 percent per year. Interest on an
2 overdue payment for a noncontested overpayment payment of a
3 claim begins on the 36th day after receipt of a claim of
4 overpayment. Interest on an overdue payment of a contested
5 overpayment of a claim begins on the 120th day after receipt
6 of a claim for overpayment.
7 (b) A claim for overpayment shall not be permitted
8 beyond 30 months after the organization's payment of a claim
9 except that claims for overpayment may be sought beyond that
10 time from providers convicted of fraud pursuant to s. 817.234.
11 (7)(a) For all contracts entered into or renewed on or
12 after October 1, 2002, an organization's internal dispute
13 resolution process related to a denied claim not under active
14 review by a mediator, arbitrator, or third-party dispute
15 entity within 60 days, must be finalized within 60 days of the
16 receipt of the provider's request for review or appeal.
17 (b) All claims to a health maintenance organization
18 begun after October 1, 2000, not under active review by a
19 mediator, arbitrator, or third-party dispute entity, shall
20 result in a final decision on the claim by the organization by
21 January 2, 2003, for the purpose of the statewide provider and
22 managed care organization claim dispute resolution program
23 pursuant to s. 408.7057.
24 (8) A provider or any representative of a provider,
25 regardless of whether the provider is under contract with the
26 health maintenance organization, may not collect or attempt to
27 collect money from, maintain any action at law against, or
28 report to a credit agency a subscriber of an organization for
29 payment of covered services for which the organization
30 contested or denied the provider's claim for not being a clean
31 claim. The prohibition applies during the pendency of any
26
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 claim for payment made by the provider to the organization for
2 payment of the services or internal dispute resolution process
3 to determine whether the claim is a clean claim and the
4 organization is liable for the services. For an electronic
5 claim, this pendency applies from the date the claim is
6 determined to be "not clean" or denied, to the date of the
7 completion of the organization's internal dispute resolution
8 process, not to exceed 180 days. For a nonelectronic claim,
9 this pendency applies from the date the claim is determined to
10 be "not clean" or denied, to the date of the completion of the
11 organization's internal dispute resolution process, not to
12 exceed 210 days.
13 (9) Any entity which contracts with a health
14 maintenance organization or its designee to furnish provider
15 services to a health maintenance organization's subscribers
16 shall comply with the provisions of this section. For the
17 purposes of regulation by the Department of Insurance, a
18 health maintenance organization shall be liable for those
19 entities' compliance, except for those providers or
20 provider-owned or provider-formed entities under contract with
21 an organization pursuant to s. 641.315.
22 (10) This section does not preclude the health
23 maintenance organization and provider from agreeing to other
24 methods of submission and receipt of claims; however, time
25 frames specified herein shall not be extended.
26 (11) A health maintenance organization may not
27 retroactively deny a claim because of subscriber ineligibility
28 more than 1 year after the date of payment of the claim.
29 (12) A health maintenance organization shall pay a
30 contracted primary care or admitting physician, pursuant to
31 such physician's contract, for providing inpatient services in
27
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 a contracted hospital to a subscriber, if such services are
2 determined by the organization to be medically necessary and
3 covered services under the organization's contract with the
4 contract holder.
5 (13) A provider who has a provider contract with the
6 health maintenance organization must include on the claim form
7 the amount due according to the terms of the contract.
8 (14)(a) Without regard to any other remedy or relief
9 to which a person is entitled, or obligated to under contract,
10 anyone aggrieved by a violation of this section may bring an
11 action to obtain a declaratory judgment that an act or
12 practice violates this section and to enjoin a person who has
13 violated, is violating, or is otherwise likely to violate this
14 section.
15 (b) Except as provided in paragraph (d), in any action
16 brought by a person who has suffered a loss as a result of a
17 violation of this section, such person may recover any amounts
18 due the person under this section, including accrued interest,
19 plus attorney's fees and court costs as provided in paragraph
20 (c).
21 (c) In any civil litigation resulting from either a
22 provider, or a health maintenance organization not receiving a
23 payment or repayment of monies due under this section where
24 the losing party is found not to have paid the prevailing
25 party in accordance with this section, the prevailing party,
26 after judgment in the trial court and after exhausting all
27 appeals, if any, shall receive his or her attorney's fees and
28 costs from the losing party; provided, however, that such fees
29 shall not exceed two times the amount in controversy or
30 $5,000, whichever is greater.
31 (d) In any civil litigation brought by a person who
28
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 has suffered a loss as a result of a violation of this
2 section, if the prevailing party can demonstrate that:
3 1. The acts giving rise to a violation of this section
4 occur with such frequency as to indicate a general business
5 practice; and
6 2. The losing party has failed to exercise good faith
7 in complying with this section, when, under the circumstances,
8 it could and should have done so, had it acted fairly and
9 honestly toward the prevailing party;
10
11 the prevailing party, after judgment in trial court and after
12 exhausting all appeals, if any, shall be entitled to recover
13 up to two times the amount due the person under this section
14 and his or her attorney's fees from the losing party.
15 (e) The attorney for the prevailing party shall submit
16 a sworn affidavit of his or her time spent on the case and his
17 or her costs incurred for all the motions, hearings, and
18 appeals to the trial court.
19 (f) Any award of attorney's fees or costs shall become
20 a part of the judgment and subject to execution as the law
21 allows.
22 Section 10. Section 641.3156, Florida Statutes, is
23 amended to read:
24 641.3156 Treatment authorization; payment of claims.--
25 (1) A health maintenance organization must pay any
26 hospital-service or referral-service claim for treatment for
27 an eligible subscriber which was authorized by a provider
28 empowered by contract with the health maintenance organization
29 to authorize or direct the patient's utilization of health
30 care services and which was also authorized in accordance with
31 the health maintenance organization's current and communicated
29
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 procedures, unless the provider provided information to the
2 health maintenance organization with the willful intention to
3 misinform the health maintenance organization. For purposes of
4 this section, "authorization" consists of any requirement of a
5 provider to obtain prior approval or to provide documentation
6 relating to the necessity of a covered medical treatment or
7 service as a condition for reimbursement for the treatment or
8 service prior to the treatment or service. Each authorization
9 request from a provider must be assigned an identification
10 number by the health maintenance organization.
11 (2) Upon receipt of a request from a provider for
12 authorization, the health maintenance organization shall make
13 a determination within a reasonable time appropriate to
14 medical circumstance indicating whether the treatment or
15 services are authorized. For urgent care requests for which
16 the standard time frame for the health maintenance
17 organization to make a determination would seriously
18 jeopardize the life or health of a subscriber or would
19 jeopardize the subscriber's ability to regain maximum
20 function, a health maintenance organization must notify the
21 provider as to its determination as soon as possible taking
22 into account medical exigencies but not later than 72 hours
23 after receiving the request for authorization.
24 (3) Each response to an authorization request must be
25 assigned an identification number. Each authorization provided
26 by a health maintenance organization must include the date of
27 request of authorization, the time frame of the authorization,
28 the identification number of the authorization, place of
29 service, type of service, and patient status.
30 (4) Failure of an organization to respond to a request
31 for authorization within the specified time frames creates an
30
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 uncontestable obligation to provide reimbursement for the
2 requested treatment or service.
3 (5)(2) A claim for treatment may not be denied if a
4 provider follows the health maintenance organization's
5 authorization procedures and receives authorization for a
6 covered service for an eligible subscriber, unless the
7 provider provided information to the health maintenance
8 organization with the willful intention to misinform the
9 health maintenance organization.
10 (6) A health maintenance organization's material
11 change in authorization procedures or requirements for
12 authorization for medical treatment or services must be
13 provided, at least 30 days in advance of the change, to all
14 contracted providers and to all noncontracted providers upon
15 request. A health maintenance organization that makes such
16 procedures accessible to providers and subscribers
17 electronically, at least 30 days in advance of the change,
18 shall be deemed to be in compliance with this section. An
19 organization shall send notice to a contracted provider
20 providing notice and an effective date of the material
21 changes.
22 (7)(3) Emergency services are subject to the
23 provisions of s. 641.513 and are not subject to the provisions
24 of this section.
25 Section 11. This act shall take effect october 1,
26 2002.
27
28
29 ================ T I T L E A M E N D M E N T ===============
30 And the title is amended as follows:
31 On page 23, line 6, through page 25, line 3,
31
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 remove: all of said lines
2
3 and insert:
4 A bill to be entitled
5 An act relating to health insurance; amending
6 s. 408.7057, F.S.; redefining "managed care
7 organization"; including preferred provider
8 organizations and health insurers in the claim
9 dispute resolution program; specifying
10 timeframes for submission of supporting
11 documentation necessary for dispute resolution;
12 providing consequences for failure to comply;
13 directing the agency to notify appropriate
14 licensure and certification entities as part of
15 final orders; amending s. 627.613, F.S.;
16 revising time of payment of claims provisions
17 applicable to health insurers; providing
18 definitions; providing requirements and
19 procedures for payment, denial, or contestment
20 of claims; providing criteria and limitations;
21 requiring payment within specified periods;
22 revising rate of interest charged on overdue
23 payments; providing for electronic and
24 nonelectronic transmission of claims; providing
25 procedures for overpayment recovery; specifying
26 timeframes for adjudication of claims,
27 internally and externally; prohibiting action
28 to collect payment from an insured under
29 certain circumstances; providing applicability;
30 authorizing contractual modification of
31 provisions of law, with exception; specifying
32
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 circumstances for retroactive claim denial;
2 specifying claim payment requirements;
3 providing for billing review procedures;
4 specifying claim content; providing civil
5 causes of action; providing for award of
6 attorney's fees; creating s. 627.6135, F.S.;
7 providing procedural requirements for
8 determination and issuance of authorizations of
9 services; providing a definition; specifying
10 circumstances for authorization timeframes;
11 specifying content for response to
12 authorization requests; providing for an
13 obligation for payment, with exception;
14 providing authorization procedure notice
15 requirements; amending s. 627.651, F.S.;
16 correcting a cross reference, to conform;
17 amending s. 627.662, F.S.; specifying
18 application of certain additional provisions to
19 group, blanket, and franchise health insurance;
20 amending s. 641.234, F.S., relating to
21 administrative, provider and management
22 contracts; prohibits health maintenance
23 organization from transferring or assigning any
24 primary risk-taker duties and responsibilities
25 to any other entity; amending s. 641.30, F.S.;
26 conforming a cross reference; amending s.
27 641.3154, F.S.; modifying the circumstances
28 under which a provider knows that an
29 organization is liable for service
30 reimbursement; amending s. 641.3155, F.S.;
31 revising payment of claims provisions
33
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 applicable to health maintenance organizations;
2 providing definitions; requiring the Department
3 of Insurance to adopt rules consistent with
4 federal claim-filing standards; providing
5 requirements and procedures for payment,
6 denial, or contestment of claims; providing
7 criteria and limitations; requiring payment
8 within specified periods; revising rate of
9 interest charged on overdue payments; providing
10 for electronic and nonelectronic transmission
11 of claims; providing procedures for overpayment
12 recovery; specifying timeframes for
13 adjudication of claims internally and
14 externally; prohibiting action to collect
15 payment from an insured under certain
16 circumstances; authorizing contractual
17 modification of provisions of law, with
18 exceptions; specifying circumstances for
19 retroactive claim denial; specifying claim
20 payment requirements; authorizing contractual
21 modification of provisions of law, with
22 exception; specifying circumstances for
23 retroactive claim denial; specifying claim
24 payment requirements; specifying claim content;
25 providing payment requirements; providing civil
26 causes of action; providing for award of
27 attorney's fees; amending s. 641.3156, F.S.;
28 providing procedural requirements for
29 determination and issuance of authorizations of
30 services; providing a definition; specifying
31 circumstances for authorization timeframes;
34
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HOUSE AMENDMENT
Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 specifying content for response to
2 authorization requests; providing for an
3 obligation for payment, with exception;
4 providing authorization procedure notice
5 requirements; providing an effective date.
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