CODING: Words stricken are deletions; words underlined are additions.
SENATE AMENDMENT
Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 421980
CHAMBER ACTION
Senate House
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11 Senator Saunders moved the following amendment:
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13 Senate Amendment
14 On page 16, line 4, through
15 page 23, line 31, delete those lines
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17 and insert:
18 (1)(a) As used in this section, the term "clean claim"
19 for a noninstitutional provider means a paper or electronic
20 billing instrument submitted to the health maintenance
21 organization's designated location which consists of the HCFA
22 1500 data set, or its successor, having all mandatory entries
23 for a physician licensed under chapter 458, chapter 459,
24 chapter 460, or chapter 461 or other appropriate billing
25 instrument that has all mandatory entries for any other
26 noninstitutional provider. For institutional providers,
27 "claim" means a paper or electronic billing instrument
28 submitted to the insurer's designated location which consists
29 of the UB-92 data set, or its successor, having all mandatory
30 entries. claim submitted on a HCFA 1500 form which has no
31 defect or impropriety, including lack of required
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Amendment No. ___ Barcode 421980
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 considered not clean solely because
5 a health maintenance organization refers the claim to a
6 medical specialist within the health maintenance organization
7 for examination. If additional substantiating documentation,
8 such as the medical record or encounter data, is required from
9 a source outside the health maintenance organization, the
10 claim is considered not clean. This definition of "clean
11 claim" is repealed on the effective date of rules adopted by
12 the department which define the term "clean claim."
13 (b) Absent a written definition that is agreed upon
14 through contract, the term "clean claim" for an institutional
15 claim is a properly and accurately completed paper or
16 electronic billing instrument that consists of the UB-92 data
17 set or its successor with entries stated as mandatory by the
18 National Uniform Billing Committee.
19 (c) The department shall adopt rules to establish
20 claim forms consistent with federal claim-filing standards for
21 health maintenance organizations required by the federal
22 Health Care Financing Administration. The department may adopt
23 rules relating to coding standards consistent with Medicare
24 coding standards adopted by the federal Health Care Financing
25 Administration.
26 (2) All claims for payment, whether electronic or
27 nonelectronic:
28 (a) Are considered received on the date the claim is
29 received by the organization at its designated claims receipt
30 location.
31 (b) Must not duplicate a claim previously submitted
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Amendment No. ___ Barcode 421980
1 unless it is determined that the original claim was not
2 received or is otherwise lost. (a) A health maintenance
3 organization shall pay any clean claim or any portion of a
4 clean claim made by a contract provider for services or goods
5 provided under a contract with the health maintenance
6 organization or a clean claim made by a noncontract provider
7 which the organization does not contest or deny within 35 days
8 after receipt of the claim by the health maintenance
9 organization which is mailed or electronically transferred by
10 the provider.
11 (b) A health maintenance organization that denies or
12 contests a provider's claim or any portion of a claim shall
13 notify the provider, in writing, within 35 days after the
14 health maintenance organization receives the claim that the
15 claim is contested or denied. The notice that the claim is
16 denied or contested must identify the contested portion of the
17 claim and the specific reason for contesting or denying the
18 claim, and, if contested, must include a request for
19 additional information. If the provider submits additional
20 information, the provider must, within 35 days after receipt
21 of the request, mail or electronically transfer the
22 information to the health maintenance organization. The health
23 maintenance organization shall pay or deny the claim or
24 portion of the claim within 45 days after receipt of the
25 information.
26 (3)(a) For an electronically submitted claim, a health
27 maintenance organization shall, within 24 hours after the
28 beginning of the next business day after receipt of the claim,
29 provide electronic acknowledgement of the receipt of the claim
30 to the electronic source submitting the claim.
31 (b) For an electronically submitted claim, a health
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Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 421980
1 maintenance organization shall, within 20 days after receipt
2 of the claim, pay the claim or notify a provider if a claim is
3 denied or contested. Notice of the organization's action on
4 the claim and payment of the claim are considered to be made
5 on the date the notice or payment is mailed or electronically
6 transferred.
7 (c)1. Notification of the health maintenance
8 organization's determination of a contested claim must be
9 accompanied by an itemized list of additional information or
10 documents the organization can reasonably determine are
11 necessary to process the claim.
12 2. A provider must submit the additional information
13 or documentation, as specified on the itemized list, within 35
14 days after receipt of the notification. Failure of a provider
15 to submit by mail or electronically the additional information
16 or documentation requested within 35 days after receipt of the
17 notification may result in denial of the claim.
18 3. A health maintenance organization may not make more
19 than one request for documents under this paragraph in
20 connection with a claim unless the provider fails to submit
21 all of the requested documents to process the claim or the
22 documents submitted by the provider raise new, additional
23 issues not included in the original written itemization, in
24 which case the organization may provide the provider with one
25 additional opportunity to submit the additional documents
26 needed to process the claim. In no case may the organization
27 request duplicate documents.
28 (d) For purposes of this subsection, electronic means
29 of transmission of claims, notices, documents, forms, and
30 payment shall be used to the greatest extent possible by the
31 health maintenance organization and the provider.
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Amendment No. ___ Barcode 421980
1 (e) A claim must be paid or denied within 90 days
2 after receipt of the claim. Failure to pay or deny a claim
3 within 120 days after receipt of the claim creates an
4 uncontestable obligation to pay the claim. Payment of a claim
5 is considered made on the date the payment was received or
6 electronically transferred or otherwise delivered. An overdue
7 payment of a claim bears simple interest at the rate of 10
8 percent per year. Interest on an overdue payment for a clean
9 claim or for any uncontested portion of a clean claim begins
10 to accrue on the 36th day after the claim has been received.
11 The interest is payable with the payment of the claim.
12 (4)(a) For all nonelectronically submitted claims, a
13 health maintenance organization shall, effective November 1,
14 2003, provide to the provider acknowledgement of receipt of
15 the claim within 15 days after receipt of the claim or provide
16 the provider, within 15 days after receipt, with electronic
17 access to the status of a submitted claim.
18 (b) For all nonelectronically submitted claims, a
19 health maintenance organization shall, within 40 days after
20 receipt of the claim, pay the claim or notify a provider if a
21 claim is denied or contested. Notice of the organization's
22 action on the claim and payment of the claim are considered to
23 be made on the date the notice or payment is mailed or
24 electronically transferred.
25 (c)1. Notification of the health maintenance
26 organization's determination of a contested claim must be
27 accompanied by an itemized list of additional information or
28 documents the organization can reasonably determine are
29 necessary to process the claim.
30 2. A provider must submit the additional information
31 or documentation, as specified on the itemized list, within 35
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Amendment No. ___ Barcode 421980
1 days after receipt of the notification. Failure of a provider
2 to submit by mail or electronically the additional information
3 or documentation requested within 35 days after receipt of the
4 notification may result in denial of the claim.
5 3. A health maintenance organization may not make more
6 than one request for documents under this paragraph in
7 connection with a claim unless the provider fails to submit
8 all of the requested documents to process the claim or the
9 documents submitted by the provider raise new, additional
10 issues not included in the original written itemization, in
11 which case the organization may provide the provider with one
12 additional opportunity to submit the additional documents
13 needed to process the claim. In no case may the health
14 maintenance organization request duplicate documents.
15 (d) For purposes of this subsection, electronic means
16 of transmission of claims, notices, documents, forms, and
17 payment shall be used to the greatest extent possible by the
18 health maintenance organization and the provider.
19 (e) A claim must be paid or denied within 120 days
20 after receipt of the claim. Failure to pay or deny a claim
21 within 140 days after receipt of the claim creates an
22 uncontestable obligation to pay the claim. A health
23 maintenance organization shall pay or deny any claim no later
24 than 120 days after receiving the claim. Failure to do so
25 creates an uncontestable obligation for the health maintenance
26 organization to pay the claim to the provider.
27 (5) Payment of a claim is considered made on the date
28 the payment is mailed or electronically transferred. An
29 overdue payment of a claim bears simple interest of 12 percent
30 per year. Interest on an overdue payment for a claim or for
31 any portion of a claim begins to accrue when the claim should
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Amendment No. ___ Barcode 421980
1 have been paid, denied, or contested. The interest is payable
2 with the payment of the claim.
3 (6)(a)(5)(a) If, as a result of retroactive review of
4 coverage decisions or payment levels, a health maintenance
5 organization determines that it has made an overpayment to a
6 provider for services rendered to a subscriber, the
7 organization must make a claim for such overpayment. The
8 organization may not reduce payment to that provider for other
9 services unless the provider agrees to the reduction in
10 writing after receipt of the claim for overpayment from the
11 health maintenance organization or fails to respond to the
12 organization's claim as required in this subsection.
13 (b) A provider shall pay a claim for an overpayment
14 made by a health maintenance organization which the provider
15 does not contest or deny within 35 days after receipt of the
16 claim that is mailed or electronically transferred to the
17 provider.
18 (c) A provider that denies or contests an
19 organization's claim for overpayment or any portion of a claim
20 shall notify the organization, in writing, within 35 days
21 after the provider receives the claim that the claim for
22 overpayment is contested or denied. The notice that the claim
23 for overpayment is denied or contested must identify the
24 contested portion of the claim and the specific reason for
25 contesting or denying the claim, and, if contested, must
26 include a request for additional information. If the
27 organization submits additional information, the organization
28 must, within 35 days after receipt of the request, mail or
29 electronically transfer the information to the provider. The
30 provider shall pay or deny the claim for overpayment within 45
31 days after receipt of the information.
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Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 421980
1 (d) Payment of a claim for overpayment is considered
2 made on the date payment was received or electronically
3 transferred or otherwise delivered to the organization, or the
4 date that the provider receives a payment from the
5 organization that reduces or deducts the overpayment. An
6 overdue payment of a claim bears simple interest at the rate
7 of 12 10 percent a year. Interest on an overdue payment of a
8 claim for overpayment or for any uncontested portion of a
9 claim for overpayment begins to accrue on the 36th day after
10 the claim for overpayment has been received.
11 (e) A provider shall pay or deny any claim for
12 overpayment no later than 120 days after receiving the claim.
13 Failure to do so creates an uncontestable obligation for the
14 provider to pay the claim to the organization.
15 (7)(6) Any retroactive reductions of payments or
16 demands for refund of previous overpayments which are due to
17 retroactive review-of-coverage decisions or payment levels
18 must be reconciled to specific claims unless the parties agree
19 to other reconciliation methods and terms. Any retroactive
20 demands by providers for payment due to underpayments or
21 nonpayments for covered services must be reconciled to
22 specific claims unless the parties agree to other
23 reconciliation methods and terms. The look-back or
24 audit-review period shall not exceed 2 years after the date
25 the claim was paid by the health maintenance organization,
26 unless fraud in billing is involved. The look-back period may
27 be specified by the terms of the contract.
28 (8)(a)(7)(a) A provider claim for payment shall be
29 considered received by the health maintenance organization, if
30 the claim has been electronically transmitted to the health
31 maintenance organization, when receipt is verified
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Bill No. CS for CS for SB 362
Amendment No. ___ Barcode 421980
1 electronically or, if the claim is mailed to the address
2 disclosed by the organization, on the date indicated on the
3 return receipt, or on the date the delivery receipt is signed
4 by the health maintenance organization if the claim is hand
5 delivered. A provider must wait 45 days following receipt of a
6 claim before submitting a duplicate claim.
7 (b) A health maintenance organization claim for
8 overpayment shall be considered received by a provider, if the
9 claim has been electronically transmitted to the provider,
10 when receipt is verified electronically or, if the claim is
11 mailed to the address disclosed by the provider, on the date
12 indicated on the return receipt. An organization must wait 45
13 days following the provider's receipt of a claim for
14 overpayment before submitting a duplicate claim.
15 (c) This section does not preclude the health
16 maintenance organization and provider from agreeing to other
17 methods of submission transmission and receipt of claims.
18 (9)(8) A provider, or the provider's designee, who
19 bills electronically is entitled to electronic acknowledgment
20 of the receipt of a claim within 72 hours.
21 (10)(9) A health maintenance organization may not
22 retroactively deny a claim because of subscriber ineligibility
23 if the provider can document receipt of subscriber eligibility
24 confirmation by the organization prior to the date or time
25 covered services were provided. Every health maintenance
26 organization contract with an employer shall include a
27 provision that requires the employer to notify the health
28 maintenance organization of changes in eligibility status
29 within 30 days more than 1 year after the date of payment of
30 the clean claim. Any person who knowingly misinforms a
31 provider prior to the receipt of services as to his or her
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Amendment No. ___ Barcode 421980
1 coverage eligibility commits insurance fraud punishable as
2 provided in s. 817.50.
3 (11)(10) A health maintenance organization shall pay a
4 contracted primary care or admitting physician, pursuant to
5 such physician's contract, for providing inpatient services in
6 a contracted hospital to a subscriber, if such services are
7 determined by the organization to be medically necessary and
8 covered services under the organization's contract with the
9 contract holder.
10 (12)(a) Without regard to any other remedy or relief
11 to which a person is entitled, or obligated to under contract,
12 anyone aggrieved by a violation of this section may bring an
13 action to obtain a declaratory judgment that an act or
14 practice violates this section and to enjoin a person who has
15 violated, is violating, or is otherwise likely to violate this
16 section.
17 (b) In any action brought by a person who has suffered
18 a loss as a result of a violation of this section, such person
19 may recover any amounts due the person under this section,
20 including accrued interest, plus attorney's fees and court
21 costs as provided in paragraph (c).
22 (c) In any civil litigation resulting from an act or
23 practice involving a violation of this section by a health
24 maintenance organization in which the organization is found to
25 have violated this section, the provider, after judgment in
26 the trial court and after exhausting all appeals, if any,
27 shall receive his or her attorney's fees and costs from the
28 organization; however, such fees shall not exceed three times
29 the amount in controversy or $5,000, whichever is greater. In
30 any such civil litigation, if the organization is found not to
31 have violated this section, the organization, after judgment
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Amendment No. ___ Barcode 421980
1 in the trial court and exhaustion of all appeals, if any, may
2 receive its reasonable attorney's fees and costs from the
3 provider on any claim or defense that the court finds the
4 provider knew or should have known was not supported by the
5 material facts necessary to establish the claim or defense or
6 would not be supported by the application of then-existing law
7 as to those material facts.
8 (d) The attorney for the prevailing party shall submit
9 a sworn affidavit of his or her time spent on the case and his
10 or her costs incurred for all the motions, hearings, and
11 appeals to the trial judge who presided over the civil case.
12 (e) Any award of attorney's fees or costs shall become
13 a part of the judgment and subject to execution as the law
14 allows.
15 (13) A health maintenance organization subscriber is
16 entitled to prompt payment from the organization whenever a
17 subscriber pays an out-of-network provider for a covered
18 service and then submits a claim to the organization. The
19 organization shall pay the claim within 35 days after receipt
20 or the organization shall advise the subscriber of what
21 additional information is required to adjudicate the claim.
22 After receipt of the additional information, the organization
23 shall pay the claim within 10 days. If the organization fails
24 to pay claims submitted by subscribers within the time periods
25 specified in this subsection, the organization shall pay the
26 subscriber interest on the unpaid claim at the rate of 12
27 percent per year. Failure to pay claims and interest, if
28 applicable, within the time periods specified in this
29 subsection is a violation of the insurance code and each
30 occurrence shall be considered a separate violation.
31 (14) The provisions of this section may not be waived,
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Amendment No. ___ Barcode 421980
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