HOUSE AMENDMENT
169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
CHAMBER ACTION
Senate House
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5 ORIGINAL STAMP BELOW
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10 ______________________________________________________________
11 The Committee on Health Promotion offered the following:
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13 Amendment (with title amendment)
14 Remove everything after the enacting clause
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16 and insert:
17 Section 1. Paragraph (a) of subsection (1), paragraph
18 (c) of subsection (2), and subsection (4) of section 408.7057,
19 Florida Statutes, are amended, and paragraphs (e) and (f) are
20 added to subsection (2) of said section, 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
30 627.
31 (2)
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169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 (c) Contracts entered into or renewed on or after
2 October 1, 2000, may require exhaustion of an internal
3 dispute-resolution process as a prerequisite to the submission
4 of a claim by a provider, or health maintenance organization,
5 or health insurer to the resolution organization when the
6 dispute-resolution program becomes effective.
7 (e) The resolution organization shall require the
8 managed care organization or provider submitting the claim
9 dispute to submit any supporting documentation to the
10 resolution organization within 15 days after receipt by the
11 managed care organization or provider of a request from the
12 resolution organization for documentation in support of the
13 claim dispute. Failure to submit the supporting documentation
14 within such time period shall result in the dismissal of the
15 submitted claim dispute.
16 (f) The resolution organization shall require the
17 respondent in the claim dispute to submit all documentation in
18 support of its position within 15 days after receiving a
19 request from the resolution organization for supporting
20 documentation. Failure to submit the supporting documentation
21 within such time period shall result in a default against the
22 managed care organization or provider. In the event of such a
23 default, the resolution organization shall issue its written
24 recommendation to the agency that a default be entered against
25 the defaulting entity. The written recommendation shall
26 include a recommendation to the agency that the defaulting
27 entity shall pay the entity submitting the claim dispute the
28 full amount of the claim dispute, plus all accrued interest.
29 (4) Within 30 days after receipt of the recommendation
30 of the resolution organization, the agency shall adopt the
31 recommendation as a final order. The agency may issue a final
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HOUSE AMENDMENT
169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 order imposing fines or sanctions, including those contained
2 in s. 641.52. All fines collected under this subsection shall
3 be deposited into the Health Care Trust Fund.
4 Section 2. Section 627.613, Florida Statutes, is
5 amended to read:
6 627.613 Time of payment of claims.--
7 (1) The contract shall include the following
8 provision:
9
10 "Time of Payment of Claims: After receiving written
11 proof of loss, the insurer will pay monthly all benefits then
12 due for (type of benefit). Benefits for any other loss covered
13 by this policy will be paid as soon as the insurer receives
14 proper written proof."
15
16 (2) Health insurers shall reimburse all claims or any
17 portion of any claim from an insured or an insured's
18 assignees, for payment under a health insurance policy, within
19 35 45 days after receipt of the claim by the health insurer.
20 If a claim or a portion of a claim is contested by the health
21 insurer, the insured or the insured's assignees shall be
22 notified, in writing, that the claim is contested or denied,
23 within 35 45 days after receipt of the claim by the health
24 insurer. The notice that a claim is contested shall identify
25 the contested portion of the claim, and the specific reasons
26 for contesting the claim, and written itemization of any
27 additional information or additional documents needed to
28 process the claim or the contested portion of the claim. A
29 health insurer may not make more than one request under this
30 subsection in connection with a claim unless the provider
31 fails to submit all of the requested information to process
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HOUSE AMENDMENT
169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 the claim or if information submitted by the provider raises
2 new, additional issues not included in the original written
3 itemization, in which case the health insurer may provide the
4 health care provider with one additional opportunity to submit
5 the additional information needed to process the claim. In no
6 case may the health insurer request duplicate information.
7 (3) A health insurer, upon receipt of the additional
8 information requested from the insured or the insured's
9 assignees shall pay or deny the contested claim or portion of
10 the contested claim, within 35 60 days.
11 (4) A health An insurer shall pay or deny any claim no
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) Payment of a claim is considered shall be treated
16 as being made on the date the payment was electronically
17 transferred or otherwise delivered a draft or other valid
18 instrument which is equivalent to payment was placed in the
19 United States mail in a properly addressed, postpaid envelope
20 or, if not so posted, on the date of delivery.
21 (6) All overdue payments shall bear simple interest at
22 the rate of 12 10 percent per year. Interest on a late payment
23 of a claim or uncontested portion of a claim begins to accrue
24 on the 36th day after the claim has been received. Interest
25 due is payable with the payment of the claim.
26 (7) Upon written notification by an insured, an
27 insurer shall investigate any claim of improper billing by a
28 physician, hospital, or other health care provider. The
29 insurer shall determine if the insured was properly billed for
30 only those procedures and services that the insured actually
31 received. If the insurer determines that the insured has been
4
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HOUSE AMENDMENT
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Amendment No. ___ (for drafter's use only)
1 improperly billed, the insurer shall notify the insured and
2 the provider of its findings and shall reduce the amount of
3 payment to the provider by the amount determined to be
4 improperly billed. If a reduction is made due to such
5 notification by the insured, the insurer shall pay to the
6 insured 20 percent of the amount of the reduction up to $500.
7 (8) A provider claim for payment shall be considered
8 received by the health insurer, if the claim has been
9 electronically transmitted to the health insurer, when receipt
10 is verified electronically or, if the claim is mailed to the
11 address disclosed by the organization, on the date indicated
12 on the return receipt. A provider must wait 35 days following
13 receipt of a claim before submitting a duplicate claim.
14 (9)(a) If, as a result of retroactive review of
15 coverage decisions or payment levels, a health insurer
16 determines that it has made an overpayment to a provider for
17 services rendered to an insured, the health insurer must make
18 a claim for such overpayment. The health insurer may not
19 reduce payment to that provider for other services unless the
20 provider agrees to the reduction or fails to respond to the
21 health insurer's claim as required in this subsection.
22 (b) A provider shall pay a claim for an overpayment
23 made by a health insurer that the provider does not contest or
24 deny within 35 days after receipt of the claim that is mailed
25 or electronically transferred to the provider.
26 (c) A provider that denies or contests a health
27 insurer's claim for overpayment or any portion of a claim
28 shall notify the health insurer, in writing, within 35 days
29 after the provider receives the claim that the claim for
30 overpayment is contested or denied. The notice that the claim
31 for overpayment is contested or denied must identify the
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HOUSE AMENDMENT
169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 contested portion of the claim and the specific reason for
2 contesting or denying the claim, and, if contested, must
3 include a request for additional information. The provider
4 shall pay or deny the claim for overpayment within 35 days
5 after receipt of the information.
6 (d) Payment of a claim for overpayment is considered
7 made on the date payment was electronically transferred or
8 otherwise delivered to the organization or on the date that
9 the provider receives a payment from the organization that
10 reduces or deducts the overpayment. An overdue payment of a
11 claim bears simple interest at the rate of 12 percent per
12 year. Interest on an overdue payment of a claim for
13 overpayment or for any uncontested portion of a claim for
14 overpayment begins to accrue on the 36th day after the claim
15 for overpayment has been received.
16 (e) A provider shall pay or deny any claim for
17 overpayment no later than 120 days after receiving the claim.
18 Failure to do so creates an uncontestable obligation for the
19 provider to pay the claim to the organization.
20 (f) A health insurer's claim for overpayment shall be
21 considered received by a provider, if the claim has been
22 electronically transmitted to the provider, when receipt is
23 verified electronically, or, if the claim is mailed to the
24 address disclosed by the provider, on the date indicated on
25 the return receipt. A health insurer must wait 35 days
26 following the provider's receipt of a claim for overpayment
27 before submitting a duplicate claim.
28 (10) Any retroactive reductions of payments or demands
29 for refund of previous overpayments that are due to
30 retroactive review of coverage decisions or payment levels
31 must be reconciled to specific claims. Any retroactive demands
6
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HOUSE AMENDMENT
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Amendment No. ___ (for drafter's use only)
1 by providers for payment due to underpayments or nonpayments
2 for covered services must be reconciled to specific claims.
3 The look-back or audit review period may not exceed 1 year
4 after the date the claim was received by the health insurer.
5 (11) A health insurer may not deny a claim because of
6 subscriber ineligibility if the provider can document receipt
7 of subscriber eligibility confirmation by the health insurer
8 prior to the date or time covered services were provided. Any
9 person who knowingly and willfully misinforms a provider prior
10 to receipt of services as to his or her coverage eligibility
11 commits insurance fraud, punishable as provided in s. 817.50.
12 (12) The provisions of this section may not be waived,
13 voided, or nullified by contracts.
14 (13) Effective October 1, 2003, the provisions of this
15 section are applicable only to claims submitted
16 electronically.
17 Section 3. Section 627.6142, Florida Statutes, is
18 created to read:
19 627.6142 Treatment authorization; payment of claims.--
20 (1) For purposes of this section, "authorization"
21 includes any requirement of a provider to notify an insurer in
22 advance of providing a covered service, regardless of whether
23 the actual terminology used by the insurer includes, but is
24 not limited to, preauthorization, precertification,
25 notification, or any other similar terminology.
26 (2) A health insurer that requires authorization for
27 medical care or health care services shall provide to each
28 provider with whom the health insurer has contracted pursuant
29 to s. 627.6471 or s. 627.6472 a list of the medical care and
30 health care services that require authorization and the
31 authorization procedures used by the health insurer at the
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HOUSE AMENDMENT
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Amendment No. ___ (for drafter's use only)
1 time a contract becomes effective. A health insurer that
2 requires authorization for medical care or health care
3 services shall provide to all other providers, not later than
4 10 working days after a request is made, a list of the medical
5 care and health care services that require authorization and
6 the authorization procedures established by the insurer. The
7 medical care or health care services that require
8 authorization and the authorization procedures used by the
9 insurer shall not be modified unless written notice is
10 provided at least 30 days in advance of any material changes
11 to all affected insureds as well as to all contracted
12 providers and all other providers that had previously
13 requested in writing a list of medical care or health care
14 services that require authorization. An insurer that makes
15 such list and procedures accessible to providers and insureds
16 electronically shall be deemed to be in compliance with this
17 subsection.
18 (3) Any claim for a covered service that does not
19 require authorization that is ordered by a contracted
20 physician and entered on the medical record may not be denied.
21 If the health insurer determines that an overpayment has been
22 made, then a claim for overpayment should be submitted to the
23 provider pursuant to s. 627.613.
24 (4)(a) Any claim for treatment may not be denied if a
25 provider follows the health insurer's published authorization
26 procedures and receives authorization, unless the provider
27 submits information to the health insurer with the willful
28 intention to misinform the health insurer.
29 (b) Upon receipt of a request from a provider for
30 authorization, the health insurer shall issue a written
31 determination indicating whether the service or services are
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HOUSE AMENDMENT
169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 authorized. If the request for an authorization is for an
2 inpatient admission, the determination shall be transmitted to
3 the provider making the request in writing no later than 24
4 hours after the request is made by the provider. If the health
5 insurer denies the request for authorization, the health
6 insurer shall notify the insured at the same time the insurer
7 notifies the provider requesting the authorization. A health
8 insurer that fails to respond to a request for an
9 authorization pursuant to this paragraph within 24 hours is
10 considered to have authorized the inpatient admission and
11 payment shall not be denied.
12 (5) If the proposed medical care or health care
13 service or services involve an inpatient admission and the
14 health insurer requires an authorization as a condition of
15 payment, the health insurer shall review and issue a written
16 or electronic authorization for the total estimated length of
17 stay for the admission, based on the recommendation of the
18 patient's physician. If the proposed medical care or health
19 care service or services are to be provided to an insured who
20 is an inpatient in a health care facility and authorization is
21 required, the health insurer shall issue a written
22 determination indicating whether the proposed services are
23 authorized or denied no later than 4 hours after the request
24 is made by the provider. A health insurer who fails to respond
25 to such request within 4 hours is considered to have
26 authorized the requested medical care or health care service
27 and payment shall not be denied.
28 (6) Emergency services and care are subject to the
29 provisions of s. 641.513 and are not subject to the provisions
30 of this section, including any inpatient admission required in
31 order to stabilize the patient pursuant to federal and state
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HOUSE AMENDMENT
169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 law.
2 (7) The provisions of this section may not be waived,
3 voided, or nullified by contract.
4 (8) The provisions of this section apply to contracts
5 entered into pursuant to ss. 627.6471 and 627.6472.
6 Section 4. Subsection (4) of section 627.651, Florida
7 Statutes, is amended to read:
8 627.651 Group contracts and plans of self-insurance
9 must meet group requirements.--
10 (4) This section does not apply to any plan which is
11 established or maintained by an individual employer in
12 accordance with the Employee Retirement Income Security Act of
13 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
14 arrangement as defined in s. 624.437(1), except that a
15 multiple-employer welfare arrangement shall comply with ss.
16 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612,
17 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(8)(6).
18 This subsection does not allow an authorized insurer to issue
19 a group health insurance policy or certificate which does not
20 comply with this part.
21 Section 5. Section 627.662, Florida Statutes, is
22 amended to read:
23 627.662 Other provisions applicable.--The following
24 provisions apply to group health insurance, blanket health
25 insurance, and franchise health insurance:
26 (1) Section 627.569, relating to use of dividends,
27 refunds, rate reductions, commissions, and service fees.
28 (2) Section 627.602(1)(f) and (2), relating to
29 identification numbers and statement of deductible provisions.
30 (3) Section 627.635, relating to excess insurance.
31 (4) Section 627.638, relating to direct payment for
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Amendment No. ___ (for drafter's use only)
1 hospital or medical services.
2 (5) Section 627.640, relating to filing and
3 classification of rates.
4 (6) Section 627.614, relating to payment of claims.
5 (7) Section 627.6142, relating to treatment
6 authorizations.
7 (8)(6) Section 627.645(1), relating to denial of
8 claims.
9 (9)(7) Section 627.613, relating to time of payment of
10 claims.
11 (10)(8) Section 627.6471, relating to preferred
12 provider organizations.
13 (11)(9) Section 627.6472, relating to exclusive
14 provider organizations.
15 (12)(10) Section 627.6473, relating to combined
16 preferred provider and exclusive provider policies.
17 (13)(11) Section 627.6474, relating to provider
18 contracts.
19 Section 6. Paragraph (e) of subsection (1) of section
20 641.185, Florida Statutes, is amended, and paragraph (m) is
21 added to said subsection, to read:
22 641.185 Health maintenance organization subscriber
23 protections.--
24 (1) With respect to the provisions of this part and
25 part III, the principles expressed in the following statements
26 shall serve as standards to be followed by the Department of
27 Insurance and the Agency for Health Care Administration in
28 exercising their powers and duties, in exercising
29 administrative discretion, in administrative interpretations
30 of the law, in enforcing its provisions, and in adopting
31 rules:
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169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 (e) A health maintenance organization subscriber
2 should receive timely, concise information regarding the
3 health maintenance organization's reimbursement to providers
4 and services pursuant to ss. 641.31 and 641.31015 and is
5 entitled to prompt payment from the organization when
6 appropriate pursuant to s. 641.3155.
7 (m)1. A health maintenance organization shall
8 reimburse any claim or portion of any claim from a subscriber
9 or a subscriber's assignee for payment under a health
10 maintenance organization subscriber contract within 35 days
11 after receipt of the claim by the organization. The notice
12 that a claim is contested shall identify the contested portion
13 of the claim, the specific reasons for contesting the claim,
14 and written itemization of any additional information or
15 additional documents needed to process the claim or the
16 contested portion of the claim.
17 2. A health maintenance organization, upon receipt of
18 the additional information requested from the subscriber or
19 the subscriber's assignee, shall pay or deny the contested
20 claim or portion of the contested claim within 35 days.
21 3. A health maintenance organization shall pay or deny
22 any claim no later than 120 days after receiving the claim.
23 Failure to do so creates an incontestable obligation of the
24 health maintenance organization to pay the claim to the
25 provider.
26 4. Payment of a claim is considered made on the date
27 the payment was electronically transferred or otherwise
28 delivered.
29 5. All overdue payments shall bear simple interest at
30 the rate of 12 percent per year. Interest on a late payment of
31 a claim or uncontested portion of a claim begins to accrue on
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169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 the 36th day after the claim has been received. Interest due
2 is payable with the payment of the claim.
3 Section 7. Subsection (1) of section 641.30, Florida
4 Statutes, is amended to read:
5 641.30 Construction and relationship to other laws.--
6 (1) Every health maintenance organization shall accept
7 the standard health claim form prescribed pursuant to s.
8 641.3155 627.647.
9 Section 8. Section 641.3155, Florida Statutes, is
10 amended to read:
11 641.3155 Payment of claims.--
12 (1)(a) As used in this section, the term "clean claim"
13 for a noninstitutional provider means a paper or electronic
14 billing instrument that consists of the HCFA 1500 data set
15 that has all mandatory entries for a physician licensed under
16 chapter 458, chapter 459, chapter 460, or chapter 461 or other
17 appropriate form for any other noninstitutional provider, or
18 its successor. For institutional providers, "claim" means a
19 paper or electronic billing instrument that consists of the
20 UB-92 data set or its successor that has all mandatory entries
21 claim submitted on a HCFA 1500 form which has no defect or
22 impropriety, including lack of required substantiating
23 documentation for noncontracted providers and suppliers, or
24 particular circumstances requiring special treatment which
25 prevent timely payment from being made on the claim. A claim
26 may not be considered not clean solely because a health
27 maintenance organization refers the claim to a medical
28 specialist within the health maintenance organization for
29 examination. If additional substantiating documentation, such
30 as the medical record or encounter data, is required from a
31 source outside the health maintenance organization, the claim
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Amendment No. ___ (for drafter's use only)
1 is considered not clean. This definition of "clean claim" is
2 repealed on the effective date of rules adopted by the
3 department which define the term "clean claim."
4 (b) Absent a written definition that is agreed upon
5 through contract, the term "clean claim" for an institutional
6 claim is a properly and accurately completed paper or
7 electronic billing instrument that consists of the UB-92 data
8 set or its successor with entries stated as mandatory by the
9 National Uniform Billing Committee.
10 (c) The department shall adopt rules to establish
11 claim forms consistent with federal claim-filing standards for
12 health maintenance organizations required by the federal
13 Health Care Financing Administration. The department may adopt
14 rules relating to coding standards consistent with Medicare
15 coding standards adopted by the federal Health Care Financing
16 Administration.
17 (2)(a) A health maintenance organization shall pay any
18 clean claim or any portion of a clean claim made by a contract
19 provider for services or goods provided under a contract with
20 the health maintenance organization or a clean claim made by a
21 noncontract provider which the organization does not contest
22 or deny within 35 days after receipt of the claim by the
23 health maintenance organization which is mailed or
24 electronically submitted transferred by the provider.
25 (b) A health maintenance organization that denies or
26 contests a provider's claim or any portion of a claim shall
27 notify the provider, in writing, within 35 days after the
28 health maintenance organization receives the claim that the
29 claim is contested or denied. The notice that the claim is
30 denied or contested must identify the contested portion of the
31 claim and the specific reason for contesting or denying the
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Amendment No. ___ (for drafter's use only)
1 claim, and, if contested, must give the provider a written
2 itemization of any include a request for additional
3 information or additional documents needed to process the
4 claim or any portion of the claim that is not being paid. If
5 the provider submits additional information, the provider
6 must, within 35 days after receipt of the request, mail or
7 electronically transfer the information to the health
8 maintenance organization. The health maintenance organization
9 shall pay or deny the claim or portion of the claim within 35
10 45 days after receipt of the information. A health maintenance
11 organization may not make more than one request under this
12 paragraph in connection with a claim, unless the provider
13 fails to submit all of the requested information to process
14 the claim or if information submitted by the provider raises
15 new, additional issues not included in the original written
16 itemization, in which case the health maintenance organization
17 may provide the health care provider with one additional
18 opportunity to submit the additional information needed to
19 process the claim. In no case may the health insurer request
20 duplicate information.
21 (c) A health maintenance organization shall not deny
22 or withhold payment on a claim because the insured has not
23 paid a required deductible or copayment.
24 (3) Payment of a claim is considered made on the date
25 the payment was received or electronically transferred or
26 otherwise delivered. An overdue payment of a claim bears
27 simple interest at the rate of 12 10 percent per year.
28 Interest on an overdue payment for a clean claim or for any
29 uncontested portion of a clean claim begins to accrue on the
30 36th day after the claim has been received. The interest is
31 payable with the payment of the claim.
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Amendment No. ___ (for drafter's use only)
1 (4) A health maintenance organization shall pay or
2 deny any claim no later than 120 days after receiving the
3 claim. Failure to do so creates an uncontestable obligation
4 for the health maintenance organization to pay the claim to
5 the provider.
6 (5)(a) If, as a result of retroactive review of
7 coverage decisions or payment levels, a health maintenance
8 organization determines that it has made an overpayment to a
9 provider for services rendered to a subscriber, the
10 organization must make a claim for such overpayment. The
11 organization may not reduce payment to that provider for other
12 services unless the provider agrees to the reduction in
13 writing after receipt of the claim for overpayment from the
14 health maintenance organization or fails to respond to the
15 organization's claim as required in this subsection.
16 (b) A provider shall pay a claim for an overpayment
17 made by a health maintenance organization which the provider
18 does not contest or deny within 35 days after receipt of the
19 claim that is mailed or electronically transferred to the
20 provider, or within 35 days after receipt of the claim that is
21 submitted to the provider.
22 (c) A provider that denies or contests an
23 organization's claim for overpayment or any portion of a claim
24 shall notify the organization, in writing, within 35 days
25 after the provider receives the claim that the claim for
26 overpayment is contested or denied. The notice that the claim
27 for overpayment is denied or contested must identify the
28 contested portion of the claim and the specific reason for
29 contesting or denying the claim, and, if contested, must
30 include a request for additional information. If the
31 organization submits additional information, the organization
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Amendment No. ___ (for drafter's use only)
1 must, within 35 days after receipt of the request, mail or
2 electronically transfer the information to the provider. The
3 provider shall pay or deny the claim for overpayment within 45
4 days after receipt of the information.
5 (d) Payment of a claim for overpayment is considered
6 made on the date payment was received or electronically
7 transferred or otherwise delivered to the organization, or the
8 date that the provider receives a payment from the
9 organization that reduces or deducts the overpayment. An
10 overdue payment of a claim bears simple interest at the rate
11 of 12 10 percent a year. Interest on an overdue payment of a
12 claim for overpayment or for any uncontested portion of a
13 claim for overpayment begins to accrue on the 36th day after
14 the claim for overpayment has been received.
15 (e) A provider shall pay or deny any claim for
16 overpayment no later than 120 days after receiving the claim.
17 Failure to do so creates an uncontestable obligation for the
18 provider to pay the claim to the organization.
19 (6) Any retroactive reductions of payments or demands
20 for refund of previous overpayments which are due to
21 retroactive review-of-coverage decisions or payment levels
22 must be reconciled to specific claims unless the parties agree
23 to other reconciliation methods and terms. Any retroactive
24 demands by providers for payment due to underpayments or
25 nonpayments for covered services must be reconciled to
26 specific claims unless the parties agree to other
27 reconciliation methods and terms. The look-back or audit
28 review period shall not exceed 1 year after the date the claim
29 was received by the health maintenance organization may be
30 specified by the terms of the contract.
31 (7)(a) A provider claim for payment shall be
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1 considered received by the health maintenance organization, if
2 the claim has been electronically transmitted to the health
3 maintenance organization, when receipt is verified
4 electronically or, if the claim is mailed to the address
5 disclosed by the organization, on the date indicated on the
6 return receipt. A provider must wait 45 days following receipt
7 of a claim before submitting a duplicate claim.
8 (b) A health maintenance organization claim for
9 overpayment shall be considered received by a provider, if the
10 claim has been electronically transmitted to the provider,
11 when receipt is verified electronically or, if the claim is
12 mailed to the address disclosed by the provider, on the date
13 indicated on the return receipt. An organization must wait 45
14 days following the provider's receipt of a claim for
15 overpayment before submitting a duplicate claim.
16 (c) This section does not preclude the health
17 maintenance organization and provider from agreeing to other
18 methods of submission transmission and receipt of claims.
19 (8) A provider, or the provider's designee, who bills
20 electronically is entitled to electronic acknowledgment of the
21 receipt of a claim within 72 hours.
22 (9) A health maintenance organization may not
23 retroactively deny a claim because of subscriber ineligibility
24 if the provider can document receipt of subscriber eligibility
25 confirmation by the organization prior to the date or time
26 covered services were provided. Every health maintenance
27 organization contract with an employer shall include a
28 provision that requires the employer to notify the health
29 maintenance organization of changes in eligibility status
30 within 30 days more than 1 year after the date of payment of
31 the clean claim. Any person who knowingly misinforms a
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169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 provider prior to the receipt of services as to his or her
2 coverage eligibility commits insurance fraud punishable as
3 provided in s. 817.50.
4 (10) A health maintenance organization shall pay a
5 contracted primary care or admitting physician, pursuant to
6 such physician's contract, for providing inpatient services in
7 a contracted hospital to a subscriber, if such services are
8 determined by the organization to be medically necessary and
9 covered services under the organization's contract with the
10 contract holder.
11 (11) A health maintenance organization subscriber is
12 entitled to prompt payment from the organization whenever a
13 subscriber pays an out-of-network provider for a covered
14 service and then submits a claim to the organization. The
15 organization shall pay the claim within 35 days after receipt
16 or the organization shall advise the subscriber of what
17 additional information is required to adjudicate the claim.
18 After receipt of the additional information, the organization
19 shall pay the claim within 10 days. If the organization fails
20 to pay claims submitted by subscribers within the time periods
21 specified in this subsection, the organization shall pay the
22 subscriber interest on the unpaid claim at the rate of 18
23 percent per year. Failure to pay claims and interest, if
24 applicable, within the time periods specified in this
25 subsection is a violation of the insurance code and each
26 occurrence shall be considered a separate violation.
27 (12) The provisions of this section may not be waived,
28 voided, or nullified by contract.
29 Section 9. Section 641.3156, Florida Statutes, is
30 amended to read:
31 641.3156 Treatment authorization; payment of claims.--
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Amendment No. ___ (for drafter's use only)
1 (1) For purposes of this section, "authorization"
2 includes any requirement of a provider to notify a health
3 maintenance organization in advance of providing a covered
4 service, regardless of whether the actual terminology used by
5 the organization includes, but is not limited to,
6 preauthorization, precertification, notification, or any other
7 similar terminology.
8 (2) A health maintenance organization that requires
9 authorization for medical care and health care services shall
10 provide to each contracted provider at the time a contract is
11 signed a list of the medical care and health care services
12 that require authorization and the authorization procedures
13 used by the organization. A health maintenance organization
14 that requires authorization for medical care and health care
15 services shall provide to each noncontracted provider, not
16 later than 10 working days after a request is made, a list of
17 the medical care and health care services that require
18 authorization and the authorization procedures used by the
19 organization. The list of medical care or health care services
20 that require authorization and the authorization procedures
21 used by the organization shall not be modified unless written
22 notice is provided at least 30 days in advance of any material
23 changes to all subscribers, contracted providers, and
24 noncontracted providers who had previously requested a list of
25 medical care or health care services that require
26 authorization. An organization that makes such list and
27 procedures accessible to providers and subscribers
28 electronically shall be deemed to be in compliance with this
29 section.
30 (3) Any claim for a covered service that does not
31 require an authorization that is ordered by a contracted
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Amendment No. ___ (for drafter's use only)
1 physician may not be denied. If an organization determines
2 that an overpayment has been made, then a claim for
3 overpayment should be submitted pursuant to s. 641.3155. A
4 health maintenance organization must pay any hospital-service
5 or referral-service claim for treatment for an eligible
6 subscriber which was authorized by a provider empowered by
7 contract with the health maintenance organization to authorize
8 or direct the patient's utilization of health care services
9 and which was also authorized in accordance with the health
10 maintenance organization's current and communicated
11 procedures, unless the provider provided information to the
12 health maintenance organization with the willful intention to
13 misinform the health maintenance organization.
14 (4)(a)(2) A claim for treatment may not be denied if a
15 provider follows the health maintenance organization's
16 authorization procedures and receives authorization for a
17 covered service for an eligible subscriber, unless the
18 provider provided information to the health maintenance
19 organization with the willful intention to misinform the
20 health maintenance organization.
21 (b) On receipt of a request from a provider for
22 authorization pursuant to this section, the health maintenance
23 organization shall issue a written determination indicating
24 whether the service or services are authorized. If the request
25 for an authorization is for an inpatient admission, the
26 determination must be transmitted to the provider making the
27 request in writing no later than 24 hours after the request is
28 made by the provider. If the organization denies the request
29 for an authorization, the health maintenance organization must
30 notify the subscriber at the same time when notifying the
31 provider requesting the authorization. A health maintenance
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Amendment No. ___ (for drafter's use only)
1 organization that fails to respond to a request for an
2 authorization from a provider pursuant to this paragraph is
3 considered to have authorized the inpatient admission within
4 24 hours and payment may not be denied.
5 (5) If the proposed medical care or health care
6 service or services involve an inpatient admission and the
7 health maintenance organization requires authorization as a
8 condition of payment, the health maintenance organization
9 shall issue a written or electronic authorization for the
10 total estimated length of stay for the admission. If the
11 proposed medical care or health care service or services are
12 to be provided to a patient who is an inpatient in a health
13 care facility at the time the services are proposed and the
14 medical care or health care service requires an authorization,
15 the health maintenance organization shall issue a
16 determination indicating whether the proposed services are
17 authorized no later than 4 hours after the request by the
18 health care provider. A health maintenance organization that
19 fails to respond to such request within 4 hours is considered
20 to have authorized the requested medical care or health care
21 service and payment may not be denied.
22 (6)(3) Emergency services are subject to the
23 provisions of s. 641.513 and are not subject to the provisions
24 of this section, including any inpatient admission required in
25 order to stabilize the patient pursuant to federal and state
26 law.
27 (7) The provisions of this section may not be waived,
28 voided, or nullified by contract.
29 Section 10. This act shall take effect October 1,
30 2002.
31
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169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 ================ T I T L E A M E N D M E N T ===============
2 And the title is amended as follows:
3 remove: the entire title
4
5 and insert:
6 A bill to be entitled
7 An act relating to health insurance; amending
8 s. 408.7057, F.S.; redefining "managed care
9 organization"; including health insurers in the
10 claim dispute resolution program; specifying
11 timeframes for submission of supporting
12 documentation necessary for dispute resolution;
13 providing consequences for failure to comply;
14 authorizing the agency to impose fines and
15 sanctions as part of final orders; amending s.
16 627.613, F.S.; revising time of payment of
17 claims provisions; providing requirements and
18 procedures for payment or denial of claims;
19 providing criteria and limitations; revising
20 rate of interest charged on overdue payments;
21 providing for electronic transmission of
22 claims; providing a penalty; prohibiting
23 contractual modification of provisions of law;
24 limiting application to claims submitted
25 electronically; creating s. 627.6142, F.S.;
26 providing a definition; requiring health
27 insurers to provide lists of medical care and
28 health care services that require
29 authorization; prohibiting denial of certain
30 claims; providing procedural requirements for
31 determination and issuance of authorizations of
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169-462AX-02 Bill No. HB 293
Amendment No. ___ (for drafter's use only)
1 services; amending s. 627.651, F.S.; correcting
2 a cross reference, to conform; amending s.
3 627.662, F.S.; specifying application of
4 certain additional provisions to group,
5 blanket, and franchise health insurance;
6 amending s. 641.185, F.S.; entitling health
7 maintenance organization subscribers to prompt
8 payment when appropriate; conforming time of
9 payment provisions; amending s. 641.30, F.S.;
10 conforming a cross reference; amending s.
11 641.3155, F.S.; providing a definition;
12 deleting provisions that require the Department
13 of Insurance to adopt rules consistent with
14 federal claim-filing standards; providing
15 requirements and procedures for payment of
16 claims; requiring payment within specified
17 periods; revising rate of interest charged on
18 overdue payments; requiring employers to
19 provide notice of changes in eligibility status
20 within a specified time period; providing a
21 penalty; entitling health maintenance
22 organization subscribers to prompt payment by
23 the organization for covered services by an
24 out-of-network provider; requiring payment
25 within specified periods; providing payment
26 procedures; providing penalties; amending s.
27 641.3156, F.S.; providing a definition;
28 requiring health maintenance organizations to
29 provide lists of medical care and health care
30 services that require authorization;
31 prohibiting denial of certain claims; providing
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Amendment No. ___ (for drafter's use only)
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2 issuance of authorizations of services;
3 providing an effective date.
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