CODING: Words stricken are deletions; words underlined are additions.
HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
CHAMBER ACTION
Senate House
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5 ORIGINAL STAMP BELOW
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11 The Council for Healthy Communities 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. Effective upon this act becoming a law,
18 paragraphs (t), (u), and (v) are added to subsection (3) of
19 section 408.036, Florida Statutes, to read:
20 408.036 Projects subject to review.--
21 (3) EXEMPTIONS.--Upon request, the following projects
22 are subject to exemption from the provisions of subsection
23 (1):
24 (t) For the provision of health services, long-term
25 care hospital services, new construction, or tertiary health
26 services excluding solid organ transplant services, by an
27 existing hospital, provided that the hospital utilizes
28 existing bed capacity and does not exceed the current licensed
29 bed capacity for that facility. Utilizing existing bed
30 capacity, a hospital may offer the exempted services within
31 the hospital's respective health planning district.
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 1. In addition to any other documentation required by
2 the agency, a request for an exemption submitted under this
3 paragraph must certify that the applicant will meet and
4 continuously maintain the minimum licensure requirements
5 governing such programs adopted by the agency pursuant to
6 subparagraph 2.
7 2. The agency shall adopt minimum licensure
8 requirements by rule which govern the operation of health
9 services, long-term care hospital services, and tertiary
10 health services excluding solid organ transplant services,
11 established pursuant to the exemption provided in this
12 paragraph. The rules shall ensure that such programs:
13 a. Perform only services authorized by the exemption
14 and will not provide any other services not authorized by the
15 exemption.
16 b. Maintain sufficient appropriate equipment and
17 health personnel to ensure quality and safety.
18 c. Maintain appropriate times of operation and
19 protocols to ensure availability and appropriate referrals in
20 emergencies.
21 d. Provide a minimum of 10 percent of its services to
22 charity and Medicaid patients each year.
23 e. Establish quality outcome measures that are
24 evidence-based. The performance of quality outcome measures
25 for such programs must be at least at the 50th percentile of
26 state and national outcome measures.
27 f. Be given an opportunity to correct any deficiencies
28 as noted by the agency prior to the expiration of the
29 authorized exemption.
30 3. The exemption provided by this paragraph shall not
31 apply unless the agency determines that the program is in
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 compliance with the requirements of subparagraph 1. and that
2 the program will, after beginning operation, continuously
3 comply with the rules adopted pursuant to subparagraph 2. The
4 agency shall monitor such programs to ensure compliance with
5 the requirements of subparagraph 2.
6 4.a. The exemption for a program shall expire
7 immediately when the agency determines that the program fails
8 to comply with the rules adopted pursuant to sub-subparagraphs
9 2.a., b., and c.
10 b. Beginning 24 months after a program first begins
11 treating patients, the exemption for the program shall expire
12 when the program fails to comply with the rules adopted
13 pursuant to sub-subparagraph 2.d.
14 5. If the exemption for a program expires pursuant to
15 sub-subparagraph 4.a. or sub-subparagraph 4.b., the agency
16 shall not grant an exemption pursuant to this paragraph for a
17 program located at the same hospital until 2 years following
18 the date of the determination by the agency that the program
19 failed to comply with the rules adopted pursuant to
20 subparagraph 2.
21 (u) For the provision of adult open heart services in
22 a hospital. When a clear problem exists in access to needed
23 cardiac services, consideration must be given to creating an
24 exemption. While such needs might be addressed by the changing
25 of the specific need criteria under the certificate-of-need
26 law, the problem of protracted administrative appeals would
27 still remain. The exemption must be based upon objective
28 criteria and address and solve the twin problems of geographic
29 and temporal access. A hospital shall be exempt from the
30 certificate-of-need review for the establishment of an open
31 heart surgery program subject to the following conditions and
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 criteria:
2 1. The applicant must certify it will meet and
3 continuously maintain the minimum licensure requirements
4 adopted by the agency governing adult open heart programs,
5 including the most current guidelines of the American College
6 of Cardiology and American Heart Association Guidelines for
7 Adult Open Heart Programs.
8 2. The applicant must certify it will maintain
9 sufficient appropriate equipment and health personnel to
10 ensure quality and safety.
11 3. The applicant must certify it will maintain
12 appropriate times of operation and protocols to ensure
13 availability and appropriate referrals in the event of
14 emergencies.
15 4. The applicant can demonstrate that it is referring
16 300 or more cardiac patients from the hospital, including the
17 emergency room, per year to a hospital with cardiac services,
18 or that the average wait for transfer for 50 percent or more
19 of the cardiac patients exceeds 4 hours.
20 5. The applicant is a general acute care hospital that
21 is in operation for 3 years or more.
22 6. The applicant is performing more than 500
23 diagnostic cardiac catheterization procedures per year,
24 combined inpatient and outpatient.
25 7. The applicant has a formal agreement with an
26 existing statutory teaching hospital or cardiac program
27 performing 750 open heart cases per year which creates at a
28 minimum an external peer review process. The peer review shall
29 be conducted quarterly the first year of operation and two
30 times a year in the succeeding years until either the program
31 reaches 350 cases per year or demonstrates consistency with
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 state-adopted quality and outcome standards for the service.
2 8. The applicant payor-mix at a minimum reflects the
3 community average for Medicaid, charity care, and self-pay or
4 the applicant must certify that it will provide a minimum of 5
5 percent of Medicaid, charity care, and self-pay to open heart
6 surgery patients.
7 9. If the applicant fails to meet the established
8 criteria for open heart programs or fails to reach 300
9 surgeries per year by the end of year 3, it must show cause
10 why its exemption should not be revoked.
11 (v) For the establishment of a satellite hospital
12 through the relocation of 100 general acute care beds from an
13 existing hospital located in the same district, as defined in
14 s. 408.032(5).
15 Section 2. Subsection (5) is added to section 408.043,
16 Florida Statutes, to read:
17 408.043 Special provisions.--
18 (5) SOLE ACUTE CARE HOSPITAL IN A HIGH GROWTH
19 COUNTY.--Notwithstanding any other provision of law, an acute
20 care hospital licensed under chapter 395 may add up to 180
21 additional beds without agency review, provided such hospital
22 is located in a county that has experienced at least a
23 60-percent growth rate since 1990, is under construction on
24 January 1, 2002, is the sole acute care hospital in the
25 county, and is located such that there is no other acute care
26 hospital within a 10-mile radius of such hospital.
27 Section 3. Section 408.7057, Florida Statutes, is
28 amended to read:
29 408.7057 Statewide provider and health plan managed
30 care organization claim dispute resolution program.--
31 (1) As used in this section, the term:
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 (a) "Agency" means the Agency for Health Care
2 Administration.
3 (b)(a) "Health plan Managed care organization" means a
4 health maintenance organization or a prepaid health clinic
5 certified under chapter 641, a prepaid health plan authorized
6 under s. 409.912, or an exclusive provider organization
7 certified under s. 627.6472, or a major medical expense health
8 insurance policy, as defined in s. 627.643(2)(e), offered by a
9 group or an individual health insurer licensed pursuant to
10 chapter 624, including a preferred provider organization under
11 s. 627.6471.
12 (c)(b) "Resolution organization" means a qualified
13 independent third-party claim-dispute-resolution entity
14 selected by and contracted with the Agency for Health Care
15 Administration.
16 (2)(a) The agency for Health Care Administration shall
17 establish a program by January 1, 2001, to provide assistance
18 to contracted and noncontracted providers and health plans
19 managed care organizations for resolution of claim disputes
20 that are not resolved by the provider and the health plan
21 managed care organization. The agency shall contract with a
22 resolution organization to timely review and consider claim
23 disputes submitted by providers and health plans managed care
24 organizations and recommend to the agency an appropriate
25 resolution of those disputes. The agency shall establish by
26 rule jurisdictional amounts and methods of aggregation for
27 claim disputes that may be considered by the resolution
28 organization.
29 (b) The resolution organization shall review claim
30 disputes filed by contracted and noncontracted providers and
31 health plans managed care organizations unless the disputed
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 claim:
2 1. Is related to interest payment;
3 2. Does not meet the jurisdictional amounts or the
4 methods of aggregation established by agency rule, as provided
5 in paragraph (a);
6 3. Is part of an internal grievance in a Medicare
7 managed care organization or a reconsideration appeal through
8 the Medicare appeals process;
9 4. Is related to a health plan that is not regulated
10 by the state;
11 5. Is part of a Medicaid fair hearing pursued under 42
12 C.F.R. ss. 431.220 et seq.;
13 6. Is the basis for an action pending in state or
14 federal court; or
15 7. Is subject to a binding claim-dispute-resolution
16 process provided by contract entered into prior to October 1,
17 2000, between the provider and the managed care organization.
18 (c) Contracts entered into or renewed on or after
19 October 1, 2000, may require exhaustion of an internal
20 dispute-resolution process as a prerequisite to the submission
21 of a claim by a provider or a health plan maintenance
22 organization to the resolution organization when the
23 dispute-resolution program becomes effective.
24 (d) A contracted or noncontracted provider or health
25 plan maintenance organization may not file a claim dispute
26 with the resolution organization more than 12 months after a
27 final determination has been made on a claim by a health plan
28 or provider maintenance organization.
29 (e) The resolution organization shall require the
30 health plan or provider submitting the claim dispute to submit
31 any supporting documentation to the resolution organization
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 within 15 days after receipt by the health plan or provider of
2 a request from the resolution organization for documentation
3 in support of the claim dispute. The resolution organization
4 may extend the time if appropriate. Failure to submit the
5 supporting documentation within such time period shall result
6 in the dismissal of the submitted claim dispute.
7 (f) The resolution organization shall require the
8 respondent in the claim dispute to submit all documentation in
9 support of its position within 15 days after receiving a
10 request from the resolution organization for supporting
11 documentation. The resolution organization may extend the time
12 if appropriate. Failure to submit the supporting documentation
13 within such time period shall result in a default against the
14 health plan or provider. In the event of such a default, the
15 resolution organization shall issue its written recommendation
16 to the agency that a default be entered against the defaulting
17 entity. The written recommendation shall include a
18 recommendation to the agency that the defaulting entity shall
19 pay the entity submitting the claim dispute the full amount of
20 the claim dispute, plus all accrued interest, and shall be
21 considered a nonprevailing party for the purposes of this
22 section.
23 (g)1. If on an ongoing basis during the preceding 12
24 months, the agency has reason to believe that a pattern of
25 noncompliance with s. 627.6131 and s. 641.3155 exists on the
26 part of a particular health plan or provider, the agency shall
27 evaluate the information contained in these cases to determine
28 whether the information evidences a pattern and report its
29 findings, together with substantiating evidence, to the
30 appropriate licensure or certification entity for the health
31 plan or provider.
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 2. In addition, the agency shall prepare an annual
2 report to the Governor and the Legislature by February 1 of
3 each year, enumerating: claims dismissed; defaults issued;
4 and failures to comply with agency final orders issued under
5 this section.
6 (3) The agency shall adopt rules to establish a
7 process to be used by the resolution organization in
8 considering claim disputes submitted by a provider or health
9 plan managed care organization which must include the issuance
10 by the resolution organization of a written recommendation,
11 supported by findings of fact, to the agency within 60 days
12 after the requested information is received by the resolution
13 organization within the timeframes specified by the resolution
14 organization. In no event shall the review time exceed 90 days
15 following receipt of the initial claim dispute submission by
16 the resolution organization receipt of the claim dispute
17 submission.
18 (4) Within 30 days after receipt of the recommendation
19 of the resolution organization, the agency shall adopt the
20 recommendation as a final order.
21 (5) The agency shall notify within 7 days the
22 appropriate licensure or certification entity whenever there
23 is a violation of a final order issued by the agency pursuant
24 to this section.
25 (6)(5) The entity that does not prevail in the
26 agency's order must pay a review cost to the review
27 organization, as determined by agency rule. Such rule must
28 provide for an apportionment of the review fee in any case in
29 which both parties prevail in part. If the nonprevailing party
30 fails to pay the ordered review cost within 35 days after the
31 agency's order, the nonpaying party is subject to a penalty of
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 not more than $500 per day until the penalty is paid.
2 (7)(6) The agency for Health Care Administration may
3 adopt rules to administer this section.
4 Section 4. Subsection (1) of section 626.88, Florida
5 Statutes, is amended to read:
6 626.88 Definitions of "administrator" and "insurer".--
7 (1) For the purposes of this part, an "administrator"
8 is any person who directly or indirectly solicits or effects
9 coverage of, collects charges or premiums from, or adjusts or
10 settles claims on residents of this state in connection with
11 authorized commercial self-insurance funds or with insured or
12 self-insured programs which provide life or health insurance
13 coverage or coverage of any other expenses described in s.
14 624.33(1) or any person who, through a health care risk
15 contract as defined in s. 641.234 with an insurer or health
16 maintenance organization, provides billing and collection
17 services to health insurers and health maintenance
18 organizations on behalf of health care providers, other than
19 any of the following persons:
20 (a) An employer on behalf of such employer's employees
21 or the employees of one or more subsidiary or affiliated
22 corporations of such employer.
23 (b) A union on behalf of its members.
24 (c) An insurance company which is either authorized to
25 transact insurance in this state or is acting as an insurer
26 with respect to a policy lawfully issued and delivered by such
27 company in and pursuant to the laws of a state in which the
28 insurer was authorized to transact an insurance business.
29 (d) A health care services plan, health maintenance
30 organization, professional service plan corporation, or person
31 in the business of providing continuing care, possessing a
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 valid certificate of authority issued by the department, and
2 the sales representatives thereof, if the activities of such
3 entity are limited to the activities permitted under the
4 certificate of authority.
5 (e) An insurance agent licensed in this state whose
6 activities are limited exclusively to the sale of insurance.
7 (f) An adjuster licensed in this state whose
8 activities are limited to the adjustment of claims.
9 (g) A creditor on behalf of such creditor's debtors
10 with respect to insurance covering a debt between the creditor
11 and its debtors.
12 (h) A trust and its trustees, agents, and employees
13 acting pursuant to such trust established in conformity with
14 29 U.S.C. s. 186.
15 (i) A trust exempt from taxation under s. 501(a) of
16 the Internal Revenue Code, a trust satisfying the requirements
17 of ss. 624.438 and 624.439, or any governmental trust as
18 defined in s. 624.33(3), and the trustees and employees acting
19 pursuant to such trust, or a custodian and its agents and
20 employees, including individuals representing the trustees in
21 overseeing the activities of a service company or
22 administrator, acting pursuant to a custodial account which
23 meets the requirements of s. 401(f) of the Internal Revenue
24 Code.
25 (j) A financial institution which is subject to
26 supervision or examination by federal or state authorities or
27 a mortgage lender licensed under chapter 494 who collects and
28 remits premiums to licensed insurance agents or authorized
29 insurers concurrently or in connection with mortgage loan
30 payments.
31 (k) A credit card issuing company which advances for
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 and collects premiums or charges from its credit card holders
2 who have authorized such collection if such company does not
3 adjust or settle claims.
4 (l) A person who adjusts or settles claims in the
5 normal course of such person's practice or employment as an
6 attorney at law and who does not collect charges or premiums
7 in connection with life or health insurance coverage.
8 (m) A person approved by the Division of Workers'
9 Compensation of the Department of Labor and Employment
10 Security who administers only self-insured workers'
11 compensation plans.
12 (n) A service company or service agent and its
13 employees, authorized in accordance with ss. 626.895-626.899,
14 serving only a single employer plan, multiple-employer welfare
15 arrangements, or a combination thereof.
16 (o) Any provider or group practice, as defined in s.
17 456.053, providing services under the scope of the license of
18 the provider or the member of the group practice.
19
20 A person who provides billing and collection services to
21 health insurers and health maintenance organizations on behalf
22 of health care providers shall comply with the provisions of
23 ss. 627.6131, 641.3155, and 641.51(4).
24 Section 5. Section 627.6131, Florida Statutes, is
25 created to read:
26 627.6131 Payment of claims.--
27 (1) The contract shall include the following
28 provision:
29
30 "Time of Payment of Claims: After receiving
31 written proof of loss, the insurer will pay
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 monthly all benefits then due for ...(type of
2 benefit).... Benefits for any other loss
3 covered by this policy will be paid as soon as
4 the insurer receives proper written proof."
5
6 (2) As used in this section, the term "claim" for a
7 noninstitutional provider means a paper or electronic billing
8 instrument submitted to the insurer's designated location that
9 consists of the HCFA 1500 data set, or its successor, that has
10 all mandatory entries for a physician licensed under chapter
11 458, chapter 459, chapter 460, chapter 461, chapter 463, or
12 chapter 490 or any appropriate billing instrument that has all
13 mandatory entries for any other noninstitutional provider. For
14 institutional providers, "claim" means a paper or electronic
15 billing instrument submitted to the insurer's designated
16 location that consists of the UB-92 data set or its successor
17 that has all mandatory entries.
18 (3) All claims for payment, whether electronic or
19 nonelectronic:
20 (a) Are considered received on the date the claim is
21 received by the insurer at its designated claims receipt
22 location.
23 (b) Must be mailed or electronically transferred to an
24 insurer within 9 months after completion of the service and
25 the provider is furnished with the correct name and address of
26 the patient's health insurer.
27 (c) Must not duplicate a claim previously submitted
28 unless it is determined that the original claim was not
29 received or is otherwise lost.
30 (4) For all electronically submitted claims, a health
31 insurer shall:
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 (a) Within 24 hours after the beginning of the next
2 business day after receipt of the claim, provide electronic
3 acknowledgment of the receipt of the claim to the electronic
4 source submitting the claim.
5 (b) Within 20 days after receipt of the claim, pay the
6 claim or notify a provider or designee if a claim is denied or
7 contested. Notice of the insurer's action on the claim and
8 payment of the claim is considered to be made on the date the
9 notice or payment was mailed or electronically transferred.
10 (c)1. Notification of the health insurer's
11 determination of a contested claim must be accompanied by an
12 itemized list of additional information or documents the
13 insurer can reasonably determine are necessary to process the
14 claim.
15 2. A provider must submit the additional information
16 or documentation, as specified on the itemized list, within 35
17 days after receipt of the notification. Failure of a provider
18 to submit by mail or electronically the additional information
19 or documentation requested within 35 days after receipt of the
20 notification may result in denial of the claim.
21 3. A health insurer may not make more than one request
22 for documents under this paragraph in connection with a claim,
23 unless the provider fails to submit all of the requested
24 documents to process the claim or if documents submitted by
25 the provider raise new additional issues not included in the
26 original written itemization, in which case the health insurer
27 may provide the provider with one additional opportunity to
28 submit the additional documents needed to process the claim.
29 In no case may the health insurer request duplicate documents.
30 (d) For purposes of this subsection, electronic means
31 of transmission of claims, notices, documents, forms, and
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 payments shall be used to the greatest extent possible by the
2 health insurer and the provider.
3 (e) A claim must be paid or denied within 90 days
4 after receipt of the claim. Failure to pay or deny a claim
5 within 120 days after receipt of the claim creates an
6 uncontestable obligation to pay the claim.
7 (5) For all nonelectronically submitted claims, a
8 health insurer shall:
9 (a) Effective November 1, 2003, provide acknowledgment
10 of receipt of the claim within 15 days after receipt of the
11 claim to the provider or provide a provider within 15 days
12 after receipt with electronic access to the status of a
13 submitted claim.
14 (b) Within 40 days after receipt of the claim, pay the
15 claim or notify a provider or designee if a claim is denied or
16 contested. Notice of the insurer's action on the claim and
17 payment of the claim is considered to be made on the date the
18 notice or payment was mailed or electronically transferred.
19 (c)1. Notification of the health insurer's
20 determination of a contested claim must be accompanied by an
21 itemized list of additional information or documents the
22 insurer can reasonably determine are necessary to process the
23 claim.
24 2. A provider must submit the additional information
25 or documentation, as specified on the itemized list, within 35
26 days after receipt of the notification. Failure of a provider
27 to submit by mail or electronically the additional information
28 or documentation requested within 35 days after receipt of the
29 notification may result in denial of the claim.
30 3. A health insurer may not make more than one request
31 for documents under this paragraph in connection with a claim
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 unless the provider fails to submit all of the requested
2 documents to process the claim or if documents submitted by
3 the provider raise new additional issues not included in the
4 original written itemization, in which case the health insurer
5 may provide the provider with one additional opportunity to
6 submit the additional documents needed to process the claim.
7 In no case may the health insurer request duplicate documents.
8 (d) For purposes of this subsection, electronic means
9 of transmission of claims, notices, documents, forms, and
10 payments shall be used to the greatest extent possible by the
11 health insurer and the provider.
12 (e) A claim must be paid or denied within 120 days
13 after receipt of the claim. Failure to pay or deny a claim
14 within 140 days after receipt of the claim creates an
15 uncontestable obligation to pay the claim.
16 (6) If a health insurer determines that it has made an
17 overpayment to a provider for services rendered to an insured,
18 the health insurer must make a claim for such overpayment. A
19 health insurer that makes a claim for overpayment to a
20 provider under this section shall give the provider a written
21 or electronic statement specifying the basis for the
22 retroactive denial or payment adjustment. The insurer must
23 identify the claim or claims, or overpayment claim portion
24 thereof, for which a claim for overpayment is submitted.
25 (a) If an overpayment determination is the result of
26 retroactive review or audit of coverage decisions or payment
27 levels not related to fraud, a health insurer shall adhere to
28 the following procedures:
29 1. All claims for overpayment must be submitted to a
30 provider within 30 months after the health insurer's payment
31 of the claim. A provider must pay, deny, or contest the health
16
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 insurer's claim for overpayment within 40 days after the
2 receipt of the claim. All contested claims for overpayment
3 must be paid or denied within 120 days after receipt of the
4 claim. Failure to pay or deny overpayment and claim within 140
5 days after receipt creates an uncontestable obligation to pay
6 the claim.
7 2. A provider that denies or contests a health
8 insurer's claim for overpayment or any portion of a claim
9 shall notify the health insurer, in writing, within 35 days
10 after the provider receives the claim that the claim for
11 overpayment is contested or denied. The notice that the claim
12 for overpayment is denied or contested must identify the
13 contested portion of the claim and the specific reason for
14 contesting or denying the claim and, if contested, must
15 include a request for additional information. If the health
16 insurer submits additional information, the health insurer
17 must, within 35 days after receipt of the request, mail or
18 electronically transfer the information to the provider. The
19 provider shall pay or deny the claim for overpayment within 45
20 days after receipt of the information. The notice is
21 considered made on the date the notice is mailed or
22 electronically transferred by the provider.
23 3. Failure of a health insurer to respond to a
24 provider's contesting of claim or request for additional
25 information regarding the claim within 35 days after receipt
26 of such notice may result in denial of the claim.
27 4. The health insurer may not reduce payment to the
28 provider for other services unless the provider agrees to the
29 reduction in writing or fails to respond to the health
30 insurer's overpayment claim as required by this paragraph.
31 5. Payment of an overpayment claim is considered made
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 on the date the payment was mailed or electronically
2 transferred. An overdue payment of a claim bears simple
3 interest at the rate of 12 percent per year. Interest on an
4 overdue payment for a claim for an overpayment begins to
5 accrue when the claim should have been paid, denied, or
6 contested.
7 (b) A claim for overpayment shall not be permitted
8 beyond 30 months after the health insurer's payment of a
9 claim, except that claims for overpayment may be sought beyond
10 that time from providers convicted of fraud pursuant to s.
11 817.234.
12 (7) Payment of a claim is considered made on the date
13 the payment was mailed or electronically transferred. An
14 overdue payment of a claim bears simple interest of 12 percent
15 per year. Interest on an overdue payment for a claim or for
16 any portion of a claim begins to accrue when the claim should
17 have been paid, denied, or contested. The interest is payable
18 with the payment of the claim.
19 (8) For all contracts entered into or renewed on or
20 after October 1, 2002, a health insurer's internal dispute
21 resolution process related to a denied claim not under active
22 review by a mediator, arbitrator, or third-party dispute
23 entity must be finalized within 60 days after the receipt of
24 the provider's request for review or appeal.
25 (9) A provider or any representative of a provider,
26 regardless of whether the provider is under contract with the
27 health insurer, may not collect or attempt to collect money
28 from, maintain any action at law against, or report to a
29 credit agency an insured for payment of covered services for
30 which the health insurer contested or denied the provider's
31 claim. This prohibition applies during the pendency of any
18
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 claim for payment made by the provider to the health insurer
2 for payment of the services or internal dispute resolution
3 process to determine whether the health insurer is liable for
4 the services. For a claim, this pendency applies from the
5 date the claim or a portion of the claim is denied to the date
6 of the completion of the health insurer's internal dispute
7 resolution process, not to exceed 60 days.
8 (10) The provisions of this section may not be waived,
9 voided, or nullified by contract.
10 (11) A health insurer may not retroactively deny a
11 claim because of insured ineligibility more than 1 year after
12 the date of payment of the claim.
13 (12) A health insurer shall pay a contracted primary
14 care or admitting physician, pursuant to such physician's
15 contract, for providing inpatient services in a contracted
16 hospital to an insured if such services are determined by the
17 health insurer to be medically necessary and covered services
18 under the health insurer's contract with the contract holder.
19 (13) Upon written notification by an insured, an
20 insurer shall investigate any claim of improper billing by a
21 physician, hospital, or other health care provider. The
22 insurer shall determine if the insured was properly billed for
23 only those procedures and services that the insured actually
24 received. If the insurer determines that the insured has been
25 improperly billed, the insurer shall notify the insured and
26 the provider of its findings and shall reduce the amount of
27 payment to the provider by the amount determined to be
28 improperly billed. If a reduction is made due to such
29 notification by the insured, the insurer shall pay to the
30 insured 20 percent of the amount of the reduction up to $500.
31 (14) A permissible error ratio of 5 percent is
19
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 established for insurer's claims payment violations of s.
2 627.6131(4)(a), (b), (c), and (e) and (5)(a), (b), (c), and
3 (e). If the error ratio of a particular insurer does not
4 exceed the permissible error ratio of 5 percent for an audit
5 period, no fine shall be assessed for the noted claims
6 violations for the audit period. The error ratio shall be
7 determined by dividing the number of claims with violations
8 found on a statistically valid sample of claims for the audit
9 period by the total number of claims in the sample. If the
10 error ratio exceeds the permissible error ratio of 5 percent,
11 a fine may be assessed according to s. 624.4211 for those
12 claims payment violations which exceed the error ratio.
13 Notwithstanding the provisions of this section, the department
14 may fine a health insurer for claims payment violations of s.
15 627.6131(4)(e) and (5)(e) which create an uncontestable
16 obligation to pay the claim. The department shall not fine
17 insurers for violations which the department determines were
18 due to circumstances beyond the insurer's control.
19 (15) This section is applicable only to a major
20 medical expense health insurance policy as defined in s.
21 627.643(2)(e) offered by a group or an individual health
22 insurer licensed pursuant to chapter 624, including a
23 preferred provider policy under s. 627.6471 and an exclusive
24 provider organization under s. 627.6472 or a group or
25 individual insurance contract that only provides direct
26 payments to dentists for enumerated dental services.
27 (16) Notwithstanding s. 627.6131(4)(b), where an
28 electronic pharmacy claim is submitted to a pharmacy benefits
29 manager acting on behalf of a health insurer the pharmacy
30 benefits manager shall, within 30 days of receipt of the
31 claim, pay the claim or notify a provider or designee if a
20
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 claim is denied or contested. Notice of the insurer's action
2 on the claim and payment of the claim is considered to be made
3 on the date the notice or payment was mailed or electronically
4 transferred.
5 (17) Notwithstanding s. 627.6131(5)(a), effective
6 November 1, 2003, where a nonelectronic pharmacy claim is
7 submitted to a pharmacy benefits manager acting on behalf of a
8 health insurer the pharmacy benefits manager shall provide
9 acknowledgment of receipt of the claim within 30 days after
10 receipt of the claim to the provider or provide a provider
11 within 30 days after receipt with electronic access to the
12 status of a submitted claim.
13 Section 6. Section 627.6135, Florida Statutes, is
14 created to read:
15 627.6135 Treatment authorization; payment of claims.--
16 (1) For purposes of this section, "authorization"
17 consists of any requirement of a provider to obtain prior
18 approval or to provide documentation relating to the necessity
19 of a covered medical treatment or service as a condition for
20 reimbursement for the treatment or service prior to the
21 treatment or service. Each authorization request from a
22 provider must be assigned an identification number by the
23 health insurer.
24 (2) Upon receipt of a request from a provider for
25 authorization, the health insurer shall make a determination
26 within a reasonable time appropriate to medical circumstance
27 indicating whether the treatment or services are authorized.
28 For urgent care requests for which the standard timeframe for
29 the health insurer to make a determination would seriously
30 jeopardize the life or health of an insured or would
31 jeopardize the insured's ability to regain maximum function, a
21
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 health insurer must notify the provider as to its
2 determination as soon as possible taking into account medical
3 exigencies.
4 (3) Each response to an authorization request must be
5 assigned an identification number. Each authorization provided
6 by a health insurer must include the date of request of
7 authorization, a timeframe of the authorization, length of
8 stay if applicable, identification number of the
9 authorization, place of service, and type of service.
10 (4) 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 intention to misinform the health
15 insurer.
16 (5) A health insurer's requirements for authorization
17 for medical treatment or services and 30-day advance notice of
18 material change in such requirements must be provided to all
19 contracted providers and upon request to all noncontracted
20 providers. A health insurer that makes such requirements and
21 advance notices accessible to providers and insureds
22 electronically shall be deemed to be in compliance with this
23 subsection.
24 Section 7. Paragraph (a) of subsection (2) of section
25 627.6425, Florida Statutes, is amended to read:
26 627.6425 Renewability of individual coverage.--
27 (2) An insurer may nonrenew or discontinue health
28 insurance coverage of an individual in the individual market
29 based only on one or more of the following:
30 (a) The individual has failed to pay premiums, or
31 contributions, or a required copayment payable to the insurer
22
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 in accordance with the terms of the health insurance coverage
2 or the insurer has not received timely premium payments. When
3 the copayment is payable to the insurer and exceeds $300 the
4 insurer shall allow the insured up to ninety days from the
5 date of the procedure to pay the required copayment. The
6 insurer shall print in 10 point type on the Declaration of
7 Benefits page notification that the insured could be
8 terminated for failure to make any required copayment to the
9 insurer.
10 Section 8. Subsection (4) of section 627.651, Florida
11 Statutes, is amended to read:
12 627.651 Group contracts and plans of self-insurance
13 must meet group requirements.--
14 (4) This section does not apply to any plan which is
15 established or maintained by an individual employer in
16 accordance with the Employee Retirement Income Security Act of
17 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
18 arrangement as defined in s. 624.437(1), except that a
19 multiple-employer welfare arrangement shall comply with ss.
20 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612,
21 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(8)(6).
22 This subsection does not allow an authorized insurer to issue
23 a group health insurance policy or certificate which does not
24 comply with this part.
25 Section 9. Section 627.662, Florida Statutes, is
26 amended to read:
27 627.662 Other provisions applicable.--The following
28 provisions apply to group health insurance, blanket health
29 insurance, and franchise health insurance:
30 (1) Section 627.569, relating to use of dividends,
31 refunds, rate reductions, commissions, and service fees.
23
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 (2) Section 627.602(1)(f) and (2), relating to
2 identification numbers and statement of deductible provisions.
3 (3) Section 627.635, relating to excess insurance.
4 (4) Section 627.638, relating to direct payment for
5 hospital or medical services.
6 (5) Section 627.640, relating to filing and
7 classification of rates.
8 (6) Section 627.613, relating to timely payment of
9 claims, or s. 627.6131, relating to payment of claims.
10 (7) Section 627.6135, relating to treatment
11 authorizations and payment of claims.
12 (8)(6) Section 627.645(1), relating to denial of
13 claims.
14 (9)(7) Section 627.613, relating to time of payment of
15 claims.
16 (10)(8) Section 627.6471, relating to preferred
17 provider organizations.
18 (11)(9) Section 627.6472, relating to exclusive
19 provider organizations.
20 (12)(10) Section 627.6473, relating to combined
21 preferred provider and exclusive provider policies.
22 (13)(11) Section 627.6474, relating to provider
23 contracts.
24 Section 10. Subsection (2) of section 627.638, Florida
25 Statutes, is amended to read:
26 627.638 Direct payment for hospital, medical
27 services.--
28 (2) Whenever, in any health insurance claim form, an
29 insured specifically authorizes payment of benefits directly
30 to any recognized hospital or physician, the insurer shall
31 make such payment to the designated provider of such services,
24
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 unless otherwise provided in the insurance contract. However,
2 if:
3 (a) The benefit is determined to be covered under the
4 terms of the policy;
5 (b) The claim is limited to treatment of mental health
6 or substance abuse, including drug and alcohol abuse; and
7 (c) The insured authorizes the insurer, in writing, as
8 part of the claim to make direct payment of benefits to a
9 recognized hospital, physician, or other licensed provider,
10
11 payments shall be made directly to the recognized hospital,
12 physician, or other licensed provider, notwithstanding any
13 contrary provisions in the insurance contract.
14 Section 11. Paragraph (e) of subsection (1) of section
15 641.185, Florida Statutes, is amended to read:
16 641.185 Health maintenance organization subscriber
17 protections.--
18 (1) With respect to the provisions of this part and
19 part III, the principles expressed in the following statements
20 shall serve as standards to be followed by the Department of
21 Insurance and the Agency for Health Care Administration in
22 exercising their powers and duties, in exercising
23 administrative discretion, in administrative interpretations
24 of the law, in enforcing its provisions, and in adopting
25 rules:
26 (e) A health maintenance organization subscriber
27 should receive timely, concise information regarding the
28 health maintenance organization's reimbursement to providers
29 and services pursuant to ss. 641.31 and 641.31015 and should
30 receive prompt payment from the organization pursuant to s.
31 641.3155.
25
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 Section 12. Subsection (4) is added to section
2 641.234, Florida Statutes, to read:
3 641.234 Administrative, provider, and management
4 contracts.--
5 (4)(a) If a health maintenance organization, through a
6 health care risk contract, transfers to any entity the
7 obligations to pay any provider for any claims arising from
8 services provided to or for the benefit of any subscriber of
9 the organization, the health maintenance organization shall
10 remain responsible for any violations of ss. 641,3155,
11 641.3156, and 641.51(4). The provisions of ss.
12 624.418-624.4211 and 641.52 shall apply to any such
13 violations.
14 (b) As used in this subsection:
15 1. The term "health care risk contract" means a
16 contract under which an entity receives compensation in
17 exchange for providing to the health maintenance organization
18 a provider network or other services, which may include
19 administrative services.
20 2. The term "entity" means a person licensed as an
21 administrator under s. 626.88 and does not include any
22 provider or group practice, as defined in s. 456.053,
23 providing services under the scope of the license of the
24 provider or the members of the group practice.
25 Section 13. Subsection (1) of section 641.30, Florida
26 Statutes, is amended to read:
27 641.30 Construction and relationship to other laws.--
28 (1) Every health maintenance organization shall accept
29 the standard health claim form prescribed pursuant to s.
30 641.3155 627.647.
31 Section 14. Subsection (4) of section 641.3154,
26
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 Florida Statutes, is amended to read:
2 641.3154 Organization liability; provider billing
3 prohibited.--
4 (4) A provider or any representative of a provider,
5 regardless of whether the provider is under contract with the
6 health maintenance organization, may not collect or attempt to
7 collect money from, maintain any action at law against, or
8 report to a credit agency a subscriber of an organization for
9 payment of services for which the organization is liable, if
10 the provider in good faith knows or should know that the
11 organization is liable. This prohibition applies during the
12 pendency of any claim for payment made by the provider to the
13 organization for payment of the services and any legal
14 proceedings or dispute resolution process to determine whether
15 the organization is liable for the services if the provider is
16 informed that such proceedings are taking place. It is
17 presumed that a provider does not know and should not know
18 that an organization is liable unless:
19 (a) The provider is informed by the organization that
20 it accepts liability;
21 (b) A court of competent jurisdiction determines that
22 the organization is liable; or
23 (c) The department or agency makes a final
24 determination that the organization is required to pay for
25 such services subsequent to a recommendation made by the
26 Statewide Provider and Subscriber Assistance Panel pursuant to
27 s. 408.7056; or
28 (d) The agency issues a final order that the
29 organization is required to pay for such services subsequent
30 to a recommendation made by a resolution organization pursuant
31 to s. 408.7057.
27
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 Section 15. Section 641.3155, Florida Statutes, is
2 amended to read:
3 (Substantial rewording of section. See
4 s. 641.3155, F.S., for present text.)
5 641.3155 Prompt payment of claims.--
6 (1) As used in this section, the term "claim" for a
7 noninstitutional provider means a paper or electronic billing
8 instrument submitted to the health maintenance organization's
9 designated location that consists of the HCFA 1500 data set,
10 or its successor, that has all mandatory entries for a
11 physician licensed under chapter 458, chapter 459, chapter
12 460, chapter 461, chapter 463, or chapter 490 or any
13 appropriate billing instrument that has all mandatory entries
14 for any other noninstitutional provider. For institutional
15 providers, "claim" means a paper or electronic billing
16 instrument submitted to the health maintenance organization's
17 designated location that consists of the UB-92 data set or its
18 successor that has all mandatory entries.
19 (2) All claims for payment, whether electronic or
20 nonelectronic:
21 (a) Are considered received on the date the claim is
22 received by the organization at its designated claims receipt
23 location.
24 (b) Must be mailed or electronically transferred to an
25 organization within 9 months after completion of the service
26 and the provider is furnished with the correct name and
27 address of the patient's health insurer.
28 (c) Must not duplicate a claim previously submitted
29 unless it is determined that the original claim was not
30 received or is otherwise lost.
31 (3) For all electronically submitted claims, a health
28
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 maintenance organization shall:
2 (a) Within 24 hours after the beginning of the next
3 business day after receipt of the claim, provide electronic
4 acknowledgment of the receipt of the claim to the electronic
5 source submitting the claim.
6 (b) Within 20 days after receipt of the claim, pay the
7 claim or notify a provider or designee if a claim is denied or
8 contested. Notice of the organization's action on the claim
9 and payment of the claim is considered to be made on the date
10 the notice or payment was mailed or electronically
11 transferred.
12 (c)1. Notification of the health maintenance
13 organization's determination of a contested claim must be
14 accompanied by an itemized list of additional information or
15 documents the insurer can reasonably determine are necessary
16 to process the claim.
17 2. A provider must submit the additional information
18 or documentation, as specified on the itemized list, within 35
19 days after receipt of the notification. Failure of a provider
20 to submit by mail or electronically the additional information
21 or documentation requested within 35 days after receipt of the
22 notification may result in denial of the claim.
23 3. A health maintenance organization may not make more
24 than one request for documents under this paragraph in
25 connection with a claim, unless the provider fails to submit
26 all of the requested documents to process the claim or if
27 documents submitted by the provider raise new additional
28 issues not included in the original written itemization, in
29 which case the health maintenance organization may provide the
30 provider with one additional opportunity to submit the
31 additional documents needed to process the claim. In no case
29
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 may the health maintenance organization request duplicate
2 documents.
3 (d) For purposes of this subsection, electronic means
4 of transmission of claims, notices, documents, forms, and
5 payment shall be used to the greatest extent possible by the
6 health maintenance organization and the provider.
7 (e) A claim must be paid or denied within 90 days
8 after receipt of the claim. Failure to pay or deny a claim
9 within 120 days after receipt of the claim creates an
10 uncontestable obligation to pay the claim.
11 (4) For all nonelectronically submitted claims, a
12 health maintenance organization shall:
13 (a) Effective November 1, 2003, provide
14 acknowledgement of receipt of the claim within 15 days after
15 receipt of the claim to the provider or designee or provide a
16 provider or designee within 15 days after receipt with
17 electronic access to the status of a submitted claim.
18 (b) Within 40 days after receipt of the claim, pay the
19 claim or notify a provider or designee if a claim is denied or
20 contested. Notice of the health maintenance organization's
21 action on the claim and payment of the claim is considered to
22 be made on the date the notice or payment was mailed or
23 electronically transferred.
24 (c)1. Notification of the health maintenance
25 organization's determination of a contested claim must be
26 accompanied by an itemized list of additional information or
27 documents the organization can reasonably determine are
28 necessary to process the claim.
29 2. A provider must submit the additional information
30 or documentation, as specified on the itemized list, within 35
31 days after receipt of the notification. Failure of a provider
30
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 to submit by mail or electronically the additional information
2 or documentation requested within 35 days after receipt of the
3 notification may result in denial of the claim.
4 3. A health maintenance organization may not make more
5 than one request for documents under this paragraph in
6 connection with a claim unless the provider fails to submit
7 all of the requested documents to process the claim or if
8 documents submitted by the provider raise new additional
9 issues not included in the original written itemization, in
10 which case the health maintenance organization may provide the
11 provider with one additional opportunity to submit the
12 additional documents needed to process the claim. In no case
13 may the health maintenance organization request duplicate
14 documents.
15 (d) For purposes of this subsection, electronic means
16 of transmission of claims, notices, documents, forms, and
17 payments 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.
23 (5) If a health maintenance organization determines
24 that it has made an overpayment to a provider for services
25 rendered to a subscriber, the health maintenance organization
26 must make a claim for such overpayment. A health maintenance
27 organization that makes a claim for overpayment to a provider
28 under this section shall give the provider a written or
29 electronic statement specifying the basis for the retroactive
30 denial or payment adjustment. The health maintenance
31 organization must identify the claim or claims, or overpayment
31
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 claim portion thereof, for which a claim for overpayment is
2 submitted.
3 (a) If an overpayment determination is the result of
4 retroactive review or audit of coverage decisions or payment
5 levels not related to fraud, a health maintenance organization
6 shall adhere to the following procedures:
7 1. All claims for overpayment must be submitted to a
8 provider within 30 months after the health maintenance
9 organization's payment of the claim. A provider must pay,
10 deny, or contest the health maintenance organization's claim
11 for overpayment within 40 days after the receipt of the claim.
12 All contested claims for overpayment must be paid or denied
13 within 120 days after receipt of the claim. Failure to pay or
14 deny overpayment and claim within 140 days after receipt
15 creates an uncontestable obligation to pay the claim.
16 2. A provider that denies or contests a health
17 maintenance organization's claim for overpayment or any
18 portion of a claim shall notify the organization, in writing,
19 within 35 days after the provider receives the claim that the
20 claim for overpayment is contested or denied. The notice that
21 the claim for overpayment is denied or contested must identify
22 the contested portion of the claim and the specific reason for
23 contesting or denying the claim and, if contested, must
24 include a request for additional information. If the
25 organization submits additional information, the organization
26 must, within 35 days after receipt of the request, mail or
27 electronically transfer the information to the provider. The
28 provider shall pay or deny the claim for overpayment within 45
29 days after receipt of the information. The notice is
30 considered made on the date the notice is mailed or
31 electronically transferred by the provider.
32
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 3. Failure of a health maintenance organization to
2 respond to a provider's contestment of claim or request for
3 additional information regarding the claim within 35 days
4 after receipt of such notice may result in denial of the
5 claim.
6 4. The health maintenance organization may not reduce
7 payment to the provider for other services unless the provider
8 agrees to the reduction in writing or fails to respond to the
9 health maintenance organization's overpayment claim as
10 required by this paragraph.
11 5. Payment of an overpayment claim is considered made
12 on the date the payment was mailed or electronically
13 transferred. An overdue payment of a claim bears simple
14 interest at the rate of 12 percent per year. Interest on an
15 overdue payment for a claim for an overpayment payment begins
16 to accrue when the claim should have been paid, denied, or
17 contested.
18 (b) A claim for overpayment shall not be permitted
19 beyond 30 months after the health maintenance organization's
20 payment of a claim, except that claims for overpayment may be
21 sought beyond that time from providers convicted of fraud
22 pursuant to s. 817.234.
23 (6) Payment of a claim is considered made on the date
24 the payment was mailed or electronically transferred. An
25 overdue payment of a claim bears simple interest of 12 percent
26 per year. Interest on an overdue payment for a claim or for
27 any portion of a claim begins to accrue when the claim should
28 have been paid, denied, or contested. The interest is payable
29 with the payment of the claim.
30 (7)(a) For all contracts entered into or renewed on or
31 after October 1, 2002, a health maintenance organization's
33
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 internal dispute resolution process related to a denied claim
2 not under active review by a mediator, arbitrator, or
3 third-party dispute entity must be finalized within 60 days
4 after the receipt of the provider's request for review or
5 appeal.
6 (b) All claims to a health maintenance organization
7 begun after October 1, 2000, not under active review by a
8 mediator, arbitrator, or third-party dispute entity, shall
9 result in a final decision on the claim by the health
10 maintenance organization by January 2, 2003, for the purpose
11 of the statewide provider and managed care organization claim
12 dispute resolution program pursuant to s. 408.7057.
13 (8) A provider or any representative of a provider,
14 regardless of whether the provider is under contract with the
15 health maintenance organization, may not collect or attempt to
16 collect money from, maintain any action at law against, or
17 report to a credit agency a subscriber for payment of covered
18 services for which the health maintenance organization
19 contested or denied the provider's claim. This prohibition
20 applies during the pendency of any claim for payment made by
21 the provider to the health maintenance organization for
22 payment of the services or internal dispute resolution process
23 to determine whether the health maintenance organization is
24 liable for the services. For a claim, this pendency applies
25 from the date the claim or a portion of the claim is denied to
26 the date of the completion of the health maintenance
27 organization's internal dispute resolution process, not to
28 exceed 60 days.
29 (9) The provisions of this section may not be waived,
30 voided, or nullified by contract.
31 (10) A health maintenance organization may not
34
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 retroactively deny a claim because of subscriber ineligibility
2 more than 1 year after the date of payment of the claim.
3 (11) 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 health maintenance organization to be
8 medically necessary and covered services under the health
9 maintenance organization's contract with the contract holder.
10 (12) Upon written notification by a subscriber, a
11 health maintenance organization shall investigate any claim of
12 improper billing by a physician, hospital, or other health
13 care provider. The organization shall determine if the
14 subscriber was properly billed for only those procedures and
15 services that the subscriber actually received. If the
16 organization determines that the subscriber has been
17 improperly billed, the organization shall notify the
18 subscriber and the provider of its findings and shall reduce
19 the amount of payment to the provider by the amount determined
20 to be improperly billed. If a reduction is made due to such
21 notification by the insured, the insurer shall pay to the
22 insured 20 percent of the amount of the reduction up to $500.
23 (13) A permissible error ratio of 5 percent is
24 established for health maintenance organizations' claims
25 payment violations of s. 641.3155(3)(a), (b), (c), and (e) and
26 (4)(a), (b), (c), and (e). If the error ratio of a particular
27 insurer does not exceed the permissible error ratio of 5
28 percent for an audit period, no fine shall be assessed for the
29 noted claims violations for the audit period. The error ratio
30 shall be determined by dividing the number of claims with
31 violations found on a statistically valid sample of claims for
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 the audit period by the total number of claims in the sample.
2 If the error ratio exceeds the permissible error ratio of 5
3 percent, a fine may be assessed according to s. 624.4211 for
4 those claims payment violations which exceed the error ratio.
5 Notwithstanding the provisions of this section, the department
6 may fine a health maintenance organization for claims payment
7 violations of s. 641.3155(3)(e) and (4)(e) which create an
8 uncontestable obligation to pay the claim. The department
9 shall not fine organizations for violations which the
10 department determines were due to circumstances beyond the
11 organization's control.
12 (14) This section shall apply to all claims or any
13 portion of a claim submitted by a health maintenance
14 organization subscriber under a health maintenance
15 organization subscriber contract to the organization for
16 payment.
17 (15) Notwithstanding s. 641.3155(3)(b), where an
18 electronic pharmacy claim is submitted to a pharmacy benefits
19 manager acting on behalf of a health maintenance organization
20 the pharmacy benefits manager shall, within 30 days of receipt
21 of the claim, pay the claim or notify a provider or designee
22 if a claim is denied or contested. Notice of the
23 organization's action on the claim and payment of the claim is
24 considered to be made on the date the notice or payment was
25 mailed or electronically transferred.
26 (16) Notwithstanding s. 641.3155(4)(a), effective
27 November 1, 2003, where a nonelectronic pharmacy claim is
28 submitted to a pharmacy benefits manager acting on behalf of a
29 health maintenance organization the pharmacy benefits manager
30 shall provide acknowledgment of receipt of the claim within 30
31 days after receipt of the claim to the provider or provide a
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 provider within 30 days after receipt with electronic access
2 to the status of a submitted claim.
3 Section 16. Section 641.3156, Florida Statutes, is
4 amended to read:
5 641.3156 Treatment authorization; payment of claims.--
6 (1) For purposes of this section, "authorization"
7 consists of any requirement of a provider to obtain prior
8 approval or to provide documentation relating to the necessity
9 of a covered medical treatment or service as a condition for
10 reimbursement for the treatment or service prior to the
11 treatment or service. Each authorization request from a
12 provider must be assigned an identification number by the
13 health maintenance organization A health maintenance
14 organization must pay any hospital-service or referral-service
15 claim for treatment for an eligible subscriber which was
16 authorized by a provider empowered by contract with the health
17 maintenance organization to authorize or direct the patient's
18 utilization of health care services and which was also
19 authorized in accordance with the health maintenance
20 organization's current and communicated procedures, unless the
21 provider provided information to the health maintenance
22 organization with the willful intention to misinform the
23 health maintenance organization.
24 (2) A claim for treatment may not be denied if a
25 provider follows the health maintenance organization's
26 authorization procedures and receives authorization for a
27 covered service for an eligible subscriber, unless the
28 provider provided information to the health maintenance
29 organization with the willful intention to misinform the
30 health maintenance organization.
31 (3) Upon receipt of a request from a provider for
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 authorization, the health maintenance organization shall make
2 a determination within a reasonable time appropriate to
3 medical circumstance indicating whether the treatment or
4 services are authorized. For urgent care requests for which
5 the standard timeframe for the health maintenance organization
6 to make a determination would seriously jeopardize the life or
7 health of a subscriber or would jeopardize the subscriber's
8 ability to regain maximum function, a health maintenance
9 organization must notify the provider as to its determination
10 as soon as possible taking into account medical exigencies.
11 (4) Each response to an authorization request must be
12 assigned an identification number. Each authorization provided
13 by a health maintenance organization must include the date of
14 request of authorization, timeframe of the authorization,
15 length of stay if applicable, identification number of the
16 authorization, place of service, and type of service.
17 (5) A health maintenance organization's requirements
18 for authorization for medical treatment or services and 30-day
19 advance notice of material change in such requirements must be
20 provided to all contracted providers and upon request to all
21 noncontracted providers. A health maintenance organization
22 that makes such requirements and advance notices accessible to
23 providers and subscribers electronically shall be deemed to be
24 in compliance with this paragraph.
25 (6)(3) Emergency services are subject to the
26 provisions of s. 641.513 and are not subject to the provisions
27 of this section.
28 Section 17. Except as otherwise provided herein, this
29 act shall take effect October 1, 2002, and shall apply to
30 claims for services rendered after such date.
31
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (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 An act relating to health care; amending s.
7 408.036, F.S.; exempting certain services,
8 construction, or programs from
9 certificate-of-need review requirements for
10 existing health facilities under certain
11 circumstances; specifying requirements;
12 requiring the Agency for Health Care
13 Administration to adopt rules and monitor
14 programs for compliance; providing conditions
15 for expiration of an exemption and for
16 prohibiting another exemption for a specified
17 period; providing application; revising the
18 exemption from certificate-of-need requirements
19 for a satellite hospital; amending s. 408.043,
20 F.S.; specifying that certain hospitals in
21 certain counties may add additional beds
22 without agency review under certain
23 circumstances; amending s. 408.7057, F.S.;
24 redesignating a program title; revising
25 definitions; including preferred provider
26 organizations and health insurers in the claim
27 dispute resolution program; specifying
28 timeframes for submission of supporting
29 documentation necessary for dispute resolution;
30 providing consequences for failure to comply;
31 providing additional responsibilities for the
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 agency relating to patterns of claim disputes;
2 providing timeframes for review by the
3 resolution organization; directing the agency
4 to notify appropriate licensure and
5 certification entities as part of violation of
6 final orders; amending s. 626.88, F.S.;
7 redefining the term "administrator," with
8 respect to regulation of insurance
9 administrators; creating s. 627.6131, F.S.;
10 specifying payment of claims provisions
11 applicable to certain health insurers;
12 providing a definition; providing requirements
13 and procedures for paying, denying, or
14 contesting claims; providing criteria and
15 limitations; requiring payment within specified
16 periods; specifying rate of interest charged on
17 overdue payments; providing for electronic and
18 nonelectronic transmission of claims; providing
19 procedures for overpayment recovery; specifying
20 timeframes for adjudication of claims,
21 internally and externally; prohibiting action
22 to collect payment from an insured under
23 certain circumstances; providing applicability;
24 prohibiting contractual modification of
25 provisions of law; specifying circumstances for
26 retroactive claim denial; specifying claim
27 payment requirements; providing for billing
28 review procedures; specifying claim content
29 requirements; establishing a permissible error
30 ratio, specifying its applicability, and
31 providing for fines; providing specified
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 exceptions from notice and acknowledgment
2 requirements for pharmacy benefit manager
3 claims; creating s. 627.6135, F.S., relating to
4 treatment authorization; providing a
5 definition; specifying circumstances for
6 authorization timeframes; specifying content
7 for response to authorization requests;
8 providing for an obligation for payment, with
9 exception; providing authorization procedure
10 notice requirements; amending s. 627.6425,
11 F.S., relating to renewability of individual
12 coverage; providing for circumstances relating
13 to nonrenewal or discontinuance of coverage;
14 amending s. 627.651, F.S.; correcting a cross
15 reference, to conform; amending s. 627.662,
16 F.S.; specifying application of certain
17 additional provisions to group, blanket, and
18 franchise health insurance; amending s.
19 627.638, F.S.; revising requirements relating
20 to direct payment of benefits to specified
21 providers under certain circumstances; amending
22 s. 641.185, F.S.; specifying that health
23 maintenance organization subscribers should
24 receive prompt payment from the organization;
25 amending s. 641.234, F.S.; specifying
26 responsibility of a health maintenance
27 organization for certain violations under
28 certain circumstances; amending s. 641.30,
29 F.S.; conforming a cross reference; amending s.
30 641.3154, F.S.; modifying the circumstances
31 under which a provider knows that an
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 organization is liable for service
2 reimbursement; amending s. 641.3155, F.S.;
3 revising payment of claims provisions
4 applicable to certain health maintenance
5 organizations; providing a definition;
6 providing requirements and procedures for
7 paying, denying, or contesting claims;
8 providing criteria and limitations; requiring
9 payment within specified periods; revising rate
10 of interest charged on overdue payments;
11 providing for electronic and nonelectronic
12 transmission of claims; providing procedures
13 for overpayment recovery; specifying timeframes
14 for adjudication of claims, internally and
15 externally; prohibiting action to collect
16 payment from a subscriber under certain
17 circumstances; prohibiting contractual
18 modification of provisions of law; specifying
19 circumstances for retroactive claim denial;
20 specifying claim payment requirements;
21 providing for billing review procedures;
22 specifying claim content requirements;
23 establishing a permissible error ratio,
24 specifying its applicability, and providing for
25 fines; providing specified exceptions from
26 notice and acknowledgment requirements for
27 pharmacy benefit manager claims; amending s.
28 641.3156, F.S., relating to treatment
29 authorization; providing a definition;
30 specifying circumstances for authorization
31 timeframes; specifying content for response to
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HOUSE AMENDMENT
Bill No. CS for CS for SB 362, 2nd Eng.
Amendment No. 1 (for drafter's use only)
1 authorization requests; providing for an
2 obligation for payment, with exception;
3 providing authorization procedure notice
4 requirements; providing effective dates.
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