Senate Bill sb0362
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Florida Senate - 2002 SB 362
By Senator Saunders
25-299-02 See HB 293
1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 408.7057, F.S.; redefining the term "managed
4 care organization"; providing for filing
5 certain claim disputes with a
6 dispute-resolution organization under certain
7 circumstances; amending s. 627.4235, F.S.;
8 providing a definition; including prepaid
9 health plans under coordination of benefits
10 provisions; providing for coordination of
11 benefits under multiple health insurance
12 policies regardless of time periods under
13 certain circumstances; amending s. 627.613,
14 F.S.; revising time of payment of claims
15 provisions; requiring the Department of
16 Insurance to adopt rules consistent with
17 federal standards; providing requirements and
18 procedures for payment or denial of claims;
19 providing criteria and limitations; amending s.
20 627.614, F.S.; entitling insureds to prompt
21 insurer payments of claims for covered
22 services; requiring payment within specified
23 periods; providing payment procedures;
24 providing penalties; creating s. 627.6142,
25 F.S.; providing a definition; requiring health
26 insurers to provide lists of medical care and
27 health care services that require
28 authorization; prohibiting denial of certain
29 claims; providing procedural requirements for
30 determination and issuance of authorizations of
31 services; amending s. 627.6471, F.S.; revising
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Florida Senate - 2002 SB 362
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1 limitations on policies providing differing
2 schedules of payments for preferred provider
3 services and nonpreferred provider services;
4 amending s. 627.662, F.S.; specifying
5 application of certain additional provisions to
6 group, blanket, and franchise health insurance;
7 amending s. 641.185, F.S.; entitling health
8 maintenance organization subscribers to prompt
9 payment by the organization for covered
10 services by an out-of-network provider;
11 requiring payment within specified periods;
12 providing payment procedures; providing
13 penalties; amending s. 641.30, F.S.; conforming
14 a cross-reference; amending s. 641.3155, F.S.;
15 providing a definition; requiring the
16 Department of Insurance to adopt rules
17 consistent with federal claim-filing standards;
18 providing requirements and procedures for
19 payment of claims; requiring payment within
20 specified periods; requiring the payment of
21 interest on overdue payments; requiring
22 coordination of benefits; providing remedies
23 for certain violations; providing for
24 attorney's fees and costs under certain
25 circumstances; amending s. 641.3156, F.S.;
26 providing a definition; requiring health
27 maintenance organizations to provide lists of
28 medical care and health care services that
29 require authorization; prohibiting denial of
30 certain claims; providing procedural
31 requirements for determination and issuance of
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Florida Senate - 2002 SB 362
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1 authorizations of services; amending s.
2 627.651, F.S.; conforming a cross-reference;
3 repealing s. 627.647, F.S., relating to
4 standard health claim forms; providing
5 effective dates.
6
7 Be It Enacted by the Legislature of the State of Florida:
8
9 Section 1. Paragraph (a) of subsection (1) and
10 paragraph (c) of subsection (2) of section 408.7057, Florida
11 Statutes, are amended to read:
12 408.7057 Statewide provider and managed care
13 organization claim dispute resolution program.--
14 (1) As used in this section, the term:
15 (a) "Managed care organization" means a health
16 maintenance organization or a prepaid health clinic certified
17 under chapter 641, a prepaid health plan authorized under s.
18 409.912, or an exclusive provider organization certified under
19 s. 627.6472, or a preferred provider organization.
20 (2)
21 (c) Contracts entered into or renewed on or after
22 October 1, 2000, may require exhaustion of an internal
23 dispute-resolution process as a prerequisite to the submission
24 of a claim by a provider or health maintenance organization to
25 the resolution organization when the dispute-resolution
26 program becomes effective; provided that, if the internal
27 dispute-resolution process is not completed within 60 calendar
28 days after the filing of the claim dispute with the managed
29 care maintenance organization, the provider may file a claim
30 dispute with a dispute-resolution organization.
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1 Section 2. Section 627.4235, Florida Statutes, is
2 amended to read:
3 627.4235 Coordination of benefits.--
4 (1) For purposes of this section, the term
5 "coordination of benefits" or "coordinating benefits" means
6 establishing an order, or operating pursuant to an established
7 order, under which primary plans pay claims and secondary
8 plans are permitted to reduce benefits paid so that the
9 combined benefits paid under all plans do not exceed covered
10 charges.
11 (2)(1) A group hospital, medical, or surgical expense
12 policy, group health care services plan, prepaid health plan
13 licensed pursuant to chapter 641, or group-type self-insurance
14 plan that provides protection or insurance against hospital,
15 medical, or surgical expenses delivered or issued for delivery
16 in this state must contain a provision for coordinating its
17 benefits with any similar benefits provided by any other group
18 hospital, medical, or surgical expense policy, any group
19 health care services plan, prepaid health plan licensed
20 pursuant to chapter 641, or any group-type self-insurance plan
21 that provides protection or insurance against hospital,
22 medical, or surgical expenses for the same loss.
23 (3)(2) A hospital, medical, or surgical expense
24 policy, health care services plan, prepaid health plan
25 licensed pursuant to chapter 641, or self-insurance plan that
26 provides protection or insurance against hospital, medical, or
27 surgical expenses issued in this state or issued for delivery
28 in this state shall may contain a provision whereby the
29 insurer may reduce or refuse to pay benefits otherwise payable
30 thereunder solely on account of the existence of similar
31 benefits provided under insurance policies issued by the same
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Florida Senate - 2002 SB 362
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1 or another insurer, health care services plan, prepaid health
2 plan licensed pursuant to chapter 641, or self-insurance plan
3 which provides protection or insurance against hospital,
4 medical, or surgical expenses only if, as a condition of
5 coordinating benefits with another insurer, the insurers
6 together pay 100 percent of the total covered charges for
7 reasonable expenses actually incurred of the type of expense
8 within the benefits described in the policies and presented to
9 the insurer for payment.
10 (4)(3) The standards provided in subsection (3) (2)
11 apply to coordination of benefits payable under Medicare,
12 Title XVIII of the Social Security Act.
13 (5)(4) If a claim is submitted in accordance with any
14 group hospital, medical, or surgical expense policy, or in
15 accordance with any group health care service plan or
16 group-type self-insurance plan, that provides protection,
17 insurance, or indemnity against hospital, medical, or surgical
18 expenses, and the policy or any other document that provides
19 coverage includes a coordination-of-benefits provision and the
20 claim involves another policy or plan which has a
21 coordination-of-benefits provision, the following rules
22 determine the order in which benefits under the respective
23 health policies or plans will be determined:
24 (a)1. The benefits of a policy or plan which covers
25 the person as an employee, member, or subscriber, other than
26 as a dependent, are determined before those of the policy or
27 plan which covers the person as a dependent.
28 2. However, if the person is also a Medicare
29 beneficiary, and if the rule established under the Social
30 Security Act of 1965, as amended, makes Medicare secondary to
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1 the plan covering the person as a dependent of an active
2 employee, the order of benefit determination is:
3 a. First, benefits of a plan covering a person as an
4 employee, member, or subscriber.
5 b. Second, benefits of a plan of an active worker
6 covering a person as a dependent.
7 c. Third, Medicare benefits.
8 (b) Except as stated in paragraph (c), if two or more
9 policies or plans cover the same child as a dependent of
10 different parents:
11 1. The benefits of the policy or plan of the parent
12 whose birthday, excluding year of birth, falls earlier in a
13 year are determined before the benefits of the policy or plan
14 of the parent whose birthday, excluding year of birth, falls
15 later in that year; but
16 2. If both parents have the same birthday, the
17 benefits of the policy or plan which covered the parent for a
18 longer period of time are determined before those of the
19 policy or plan which covered the parent for a shorter period
20 of time.
21
22 However, if a policy or plan subject to the rule based on the
23 birthdays of the parents coordinates with an out-of-state
24 policy or plan which contains provisions under which the
25 benefits of a policy or plan which covers a person as a
26 dependent of a male are determined before those of a policy or
27 plan which covers the person as a dependent of a female and
28 if, as a result, the policies or plans do not agree on the
29 order of benefits, the provisions of the other policy or plan
30 determine the order of benefits.
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1 (c) If two or more policies or plans cover a dependent
2 child of divorced or separated parents, benefits for the child
3 are determined in this order:
4 1. First, the policy or plan of the parent with
5 custody of the child.
6 2. Second, the policy or plan of the spouse of the
7 parent with custody of the child.
8 3. Third, the policy or plan of the parent not having
9 custody of the child.
10
11 However, if the specific terms of a court decree state that
12 one of the parents is responsible for the health care expenses
13 of the child and if the entity obliged to pay or provide the
14 benefits of the policy or plan of that parent has actual
15 knowledge of those terms, the benefits of that policy or plan
16 are determined first, except with respect to any claim
17 determination period or plan or policy year during which any
18 benefits are actually paid or provided before the entity has
19 the actual knowledge.
20 (d) The benefits of a policy or plan which covers a
21 person as an employee who is neither laid off nor retired, or
22 as that employee's dependent, are determined before those of a
23 policy or plan which covers the person as a laid-off or
24 retired employee or as the employee's dependent. If the other
25 policy or plan is not subject to this rule, and if, as a
26 result, the policies or plans do not agree on the order of
27 benefits, this paragraph does not apply.
28 (e) If none of the rules in paragraph (a), paragraph
29 (b), paragraph (c), or paragraph (d) determine the order of
30 benefits, the benefits of the policy or plan which covered an
31 employee, member, or subscriber for a longer period of time
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1 are determined before those of the policy or plan which
2 covered the person for the shorter period of time.
3 (6)(5) Coordination of benefits is not permitted
4 against an indemnity-type policy, an excess insurance policy
5 as defined in s. 627.635, a policy with coverage limited to
6 specified illnesses or accidents, or a Medicare supplement
7 policy.
8 (7)(6) If an individual is covered under a COBRA
9 continuation plan as a result of the purchase of coverage as
10 provided under the Consolidation Omnibus Budget Reconciliation
11 Act of 1987 (Pub. L. No. 99-272), and also under another group
12 plan, the following order of benefits applies:
13 (a) First, the plan covering the person as an
14 employee, or as the employee's dependent.
15 (b) Second, the coverage purchased under the plan
16 covering the person as a former employee, or as the former
17 employee's dependent provided according to the provisions of
18 COBRA.
19 (8) If the insured fails to furnish the provider with
20 the correct name and address of the insured's primary insurer,
21 and the claim is submitted to a secondary insurer or prepaid
22 health plan licensed pursuant to chapter 641 and the claim is
23 subsequently rejected, the provider has 60 calendar days from
24 the date the provider obtains the correct billing information
25 to submit a claim to either the primary or secondary insurer,
26 regardless of any time periods for filing of claims
27 established by any applicable contract.
28 Section 3. Effective October 16, 2002, section
29 627.613, Florida Statutes, is amended to read:
30 (Substantial rewording of section.
31 See s. 627.613, F.S., for present text.)
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1 627.613 Time of payment of claims.--
2 (1)(a) As used in this section, for a noninstitutional
3 provider, the term "claim" means a paper or electronic billing
4 instrument that consists of the HCFA 1500 data set that has
5 all mandatory entries completed for a physician licensed under
6 chapter 458 or chapter 459 or other appropriate form for any
7 other noninstitutional provider, or its successor. For
8 institutional providers, "claim" means a paper or electronic
9 billing instrument that consists of the UB-92 data set or its
10 successor that has all mandatory entries completed.
11 (b) The department shall adopt rules to establish
12 claim forms consistent with federal claim-filing standards for
13 health insurers required by the Secretary of the United States
14 Department of Health and Human Services. The department shall
15 adopt rules to require code sets consistent with code sets
16 adopted by the Secretary of the United States Department of
17 Health and Human Services. The code sets shall apply to
18 electronic claims. A code set, as defined by the secretary,
19 includes both the codes and the descriptors of the codes and
20 shall include, but not be limited to:
21 1. Medical data code sets, including the International
22 Classification of Diseases, the HCFA Common Procedure Coding
23 System and current procedure terminology, and the HCFA Common
24 Procedure Coding System for supplies and other health care
25 items.
26 2. Health care claims or equivalent encounter
27 information for professional health care claims and
28 institutional health care claims.
29 3. Eligibility for a health plan standard.
30 4. Referral certification and authorization standard.
31 5. Health care claim status standard.
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Florida Senate - 2002 SB 362
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1 6. Enrollment and disenrollment in a health plan
2 standard.
3 7. Health care payment and remittance advice standard.
4 8. Coordination of benefits standard.
5 9. Revenue codes used by Medicare for processing
6 claims.
7 10. National Correct Coding Initiative edits used by
8 Medicare.
9 (c) All providers and payors shall use only the
10 standard code sets defined for their area of operation by the
11 Secretary of the United States Department of Health and Human
12 Services for the filing and adjudication of electronic claims.
13 The version of the code set shall be the version that is valid
14 at the time the health care is furnished, defined as the date
15 of discharge for inpatient services and date of service for
16 health care provided in an outpatient or ambulatory setting.
17 (2)(a) A health insurer shall pay any claim or any
18 portion of a claim made by a contract provider for services or
19 goods provided under a contract with the health insurer or a
20 claim made by a noncontracted provider, which the insurer does
21 not contest or deny, within 15 calendar days after receipt of
22 the claim by the health insurer that is electronically
23 submitted by the provider, or within 35 calendar days after
24 receipt of the claim by the health insurer that is submitted
25 by the provider using either hand delivery, the United States
26 mail, or a reputable overnight delivery service. The
27 investigation and determination of eligibility for payment,
28 including any coordination of any other payments, does not
29 extend the time periods specified in this paragraph.
30 (b) A health insurer that denies or contests a
31 provider's claim or any portion of a claim shall notify the
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1 provider within 35 calendar days after the health insurer
2 receives the claim, if submitted by hand delivery, United
3 States mail, or overnight delivery service, or within 15
4 calendar days after the health insurer receives the claim if
5 submitted by electronic means, that the claim is contested or
6 denied. The notice that the claim is contested or denied shall
7 identify the contested portion of the claim and the specific
8 reason for contesting or denying the claim and, if contested,
9 shall give the provider a written itemization of any
10 additional information or additional documents needed to
11 process the claim or any portion of the claim that is not
12 being paid. The health insurer shall pay or deny the claim or
13 portion of the claim within 35 calendar days after receipt of
14 the information. A health insurer may not make more than one
15 request under this paragraph in connection with a claim,
16 unless the provider fails to submit all of the requested
17 information to process the claim, in which case the health
18 insurer may provide the health care provider with one
19 additional opportunity to submit the additional information
20 needed to process the claim.
21 (c) If a health insurer requests additional
22 information or additional documents from a person other than
23 the provider who submitted the claim, the health insurer shall
24 provide a copy of the request to the provider who submitted
25 the claim. The health insurer may not withhold payment
26 pending receipt of information or documents requested under
27 this paragraph. A health insurer may not deny or withhold
28 payment on a claim because the insured has not paid a required
29 deductible or copayment.
30 (3) Payment of a claim is considered made on the date
31 the payment is received, electronically transferred, or
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1 otherwise delivered. An insurer that does not pay a claim when
2 payment is due as provided in subsection (4) shall pay the
3 provider submitting the claim the provider's billed charges
4 submitted on the claim.
5 (4) A health insurer shall pay or deny any claim no
6 later than 50 calendar days after receiving the claim if the
7 claim is submitted electronically, or no later than 70
8 calendar days if the claim is submitted by hand delivery,
9 United States mail, or a reputable overnight delivery service.
10 Failure to pay or deny a claim within such time periods
11 creates an uncontestable obligation of the health insurer to
12 pay the claim to the provider. The running of the time
13 specified in this subsection shall be tolled by the number of
14 days taken by the provider who submitted the claim to submit
15 the additional information requested by the insurer pursuant
16 to paragraph (2)(b).
17 (5) If, as a result of retroactive review of coverage
18 decisions or payment levels, a health insurer determines that
19 the insurer has made an overpayment to a provider for services
20 rendered to an insured, the insurer may not reduce payment to
21 that provider for other services. The look-back or audit
22 review period may not exceed 1 year from the date of discharge
23 or 1 year from the date the health service was provided.
24 (6) A provider claim for payment shall be considered
25 received by the health insurer, if the claim has been
26 electronically transmitted to the health insurer, when receipt
27 is verified electronically; if the claim is mailed by United
28 States mail to the address disclosed by the insurer, on the
29 date indicated on the return receipt; or, if the claim is hand
30 delivered, on the date the delivery receipt is signed by the
31 health insurer. A health insurer shall not require a provider
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1 to resubmit a claim for payment if the claim has been received
2 by the insurer. A provider shall wait 35 calendar days
3 following receipt of a claim before submitting a duplicate
4 claim.
5 (7) A health insurer shall provide a provider or the
6 provider's designee, who bills electronically, electronic
7 acknowledgment of the receipt of a claim within 24 hours after
8 receipt.
9 (8) A health insurer may not retroactively deny a
10 claim because of subscriber ineligibility.
11 (9)(a) Without regard to any other remedy or relief to
12 which a provider is entitled, any provider aggrieved by a
13 violation of this section by a health insurer may bring an
14 action to enjoin a person who has violated, or is violating,
15 this section. In any such action, the provider who has
16 suffered a loss as a result of the violation may recover any
17 amounts due the provider by the health insurer, including
18 accrued interest, plus attorney's fees and costs as provided
19 in paragraph (b).
20 (b) In any action arising out of a violation of this
21 section by a health insurer where the health insurer is found
22 to have violated this section, the provider, after judgment in
23 the trial court and after exhausting all appeals, if any,
24 shall receive his or her reasonable attorney's fees and costs
25 from the health insurer.
26 (10) The provisions of this section apply to contracts
27 entered into pursuant to ss. 627.6471 and 627.6472.
28 (11) The provisions of this section may not be waived,
29 voided, or nullified by contract.
30 Section 4. Subsection (3) is added to section 627.614,
31 Florida Statutes, to read:
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1 627.614 Payment of claims.--
2 (3) An insured is entitled to prompt payment from an
3 insurer for claims submitted for a covered service. If the
4 claim is submitted electronically by the insured or on the
5 insured's behalf, the claim shall be paid to the insured
6 within 15 days or the insurer shall advise the insured of what
7 additional information is required to adjudicate the claim.
8 After receipt of the additional information, the insurer shall
9 pay the claim within 10 days. If the claim is submitted by
10 electronic facsimile, United States mail, or overnight
11 delivery service, the insurer shall pay the claim within 30
12 days or the insurer shall advise the insured of what
13 additional information is required to adjudicate the claim.
14 After receipt of the additional information, the insurer shall
15 pay the claim within 10 days. If the insurer fails to pay a
16 claim submitted by an insured within the time periods
17 specified in this subsection, the insurer shall pay the
18 insured twice the amount of the claim. Failure to pay claims
19 and penalties, if applicable, within the time periods
20 specified in this subsection is a violation of the insurance
21 code and each occurrence shall be considered a separate
22 violation.
23 Section 5. Section 627.6142, Florida Statutes, is
24 created to read:
25 627.6142 Treatment authorization; payment of claims.--
26 (1) For purposes of this section, "authorization"
27 includes any requirement of a provider to notify an insurer in
28 advance of providing a covered service, regardless of whether
29 the actual terminology used by the insurer includes, but is
30 not limited to, preauthorization, precertification,
31 notification, or any other similar terminology.
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1 (2) A health insurer that requires authorization for
2 medical care or health care services shall provide to each
3 provider with whom the health insurer has contracted pursuant
4 to s. 627.6471 or s. 627.6472 a list of the medical care and
5 health care services that require authorization and the
6 authorization procedures used by the health insurer at the
7 time a contract becomes effective. A health insurer that
8 requires authorization for medical care or health care
9 services shall provide to all other providers, not later than
10 10 working days after a request is made, a list of the medical
11 care and health care services that require authorization and
12 the authorization procedures established by the insurer. The
13 medical care or health care services that require
14 authorization and the authorization procedures used by the
15 insurer shall not be modified unless written notice is
16 provided at least 30 days in advance of any changes to all
17 affected insureds as well as to all contracted providers and
18 all other providers that had previously requested in writing a
19 list of medical care or health care services that require
20 authorization.
21 (3) Any claim for treatment that does not require
22 authorization that is ordered by a physician and entered on
23 the medical record may not be denied.
24 (4)(a) Any claim for treatment may not be denied if a
25 provider follows the health insurer's published authorization
26 procedures and receives authorization, unless the provider
27 submits information to the health insurer with the willful
28 intention to misinform the health insurer.
29 (b) Upon receipt of a request from a provider for
30 authorization, the health insurer shall issue a determination
31 indicating whether the service or services are authorized. The
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1 determination shall be transmitted to the provider making the
2 request in writing no later than 8 hours after the request is
3 made by the provider. If the health insurer denies the request
4 for authorization, the health insurer shall notify the insured
5 at the same time the insurer notifies the provider requesting
6 the authorization. A health insurer that fails to respond to a
7 request for an authorization pursuant to this paragraph within
8 8 hours is considered to have authorized the requested medical
9 care or health care service and payment shall not be denied.
10 (5) If the proposed medical care or health care
11 service or services involve an inpatient admission and the
12 health insurer requires an authorization as a condition of
13 payment, the health insurer shall review and issue a written
14 or electronic authorization for the total estimated length of
15 stay for the admission, based on the recommendation of the
16 patient's physician. If the proposed medical care or health
17 care service or services are to be provided to an insured who
18 is an inpatient in a health care facility and authorization is
19 required, the health insurer shall issue a written
20 determination indicating whether the proposed services are
21 authorized or denied no later than 1 hour after the request is
22 made by the provider. A health insurer who fails to respond to
23 such request within 1 hour is considered to have authorized
24 the requested medical service or health care service and
25 payment shall not be denied.
26 (6) Emergency services and care are subject to the
27 provisions of s. 641.513 and are not subject to the provisions
28 of this section, including any inpatient admission required in
29 order to stabilize the patient pursuant to federal and state
30 law.
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1 (7) The provisions of this section may not be waived,
2 voided, or nullified by contract.
3 (8) The provisions of this section apply to contracts
4 entered into pursuant to ss. 627.6471 and 627.6472.
5 Section 6. Paragraph (h) of subsection (4) of section
6 627.6471, Florida Statutes, is amended to read:
7 627.6471 Contracts for reduced rates of payment;
8 limitations; coinsurance and deductibles.--
9 (4) Any policy that provides schedules of payments for
10 services provided by preferred providers that differ from the
11 schedules of payments for services provided by nonpreferred
12 providers is subject to the following limitations:
13 (h) Each preferred provider shall be given a list of
14 all payors with whom the insurer has entered into agreements
15 to use the services of the preferred provider and no
16 additional payors shall be added to the agreement unless
17 approved by the preferred provider. Neither the insurer nor
18 the insurer's claims administrator shall disclose contract
19 rate information without the written approval of the preferred
20 provider. If any service or treatment is not within the scope
21 of services provided by the network of preferred providers,
22 but is within the scope of services or treatment covered by
23 the policy, the service or treatment shall be reimbursed at a
24 rate not less than 10 percentage points lower than the
25 percentage rate paid to preferred providers. The
26 reimbursement rate must be applied to the usual and customary
27 charges in the area.
28 Section 7. Section 627.662, Florida Statutes, is
29 amended to read:
30
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1 627.662 Other provisions applicable.--The following
2 provisions apply to group health insurance, blanket health
3 insurance, and franchise health insurance:
4 (1) Section 627.569, relating to use of dividends,
5 refunds, rate reductions, commissions, and service fees.
6 (2) Section 627.602(1)(f) and (2), relating to
7 identification numbers and statement of deductible provisions.
8 (3) Section 627.635, relating to excess insurance.
9 (4) Section 627.638, relating to direct payment for
10 hospital or medical services.
11 (5) Section 627.640, relating to filing and
12 classification of rates.
13 (6) Section 627.4235, relating to coordination of
14 benefits.
15 (7) Section 627.614, relating to payment of claims.
16 (8) Section 627.6142, relating to treatment
17 authorizations.
18 (9)(6) Section 627.645(1), relating to denial of
19 claims.
20 (10)(7) Section 627.613, relating to time of payment
21 of claims.
22 (11)(8) Section 627.6471, relating to preferred
23 provider organizations.
24 (12)(9) Section 627.6472, relating to exclusive
25 provider organizations.
26 (13)(10) Section 627.6473, relating to combined
27 preferred provider and exclusive provider policies.
28 (14)(11) Section 627.6474, relating to provider
29 contracts.
30 Section 8. Paragraph (m) is added to subsection (1) of
31 section 641.185, Florida Statutes, to read:
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1 641.185 Health maintenance organization subscriber
2 protections.--
3 (1) With respect to the provisions of this part and
4 part III, the principles expressed in the following statements
5 shall serve as standards to be followed by the Department of
6 Insurance and the Agency for Health Care Administration in
7 exercising their powers and duties, in exercising
8 administrative discretion, in administrative interpretations
9 of the law, in enforcing its provisions, and in adopting
10 rules:
11 (m) A health maintenance organization subscriber is
12 entitled to prompt payment from the organization whenever a
13 subscriber pays an out-of-network provider for a covered
14 service and then submits a claim to the organization. If the
15 claim is submitted electronically by the subscriber or on the
16 subscriber's behalf by the out-of-network provider, the claim
17 shall be paid to the subscriber within 15 days or the
18 organization shall advise the subscriber of what additional
19 information is required to adjudicate the claim. After receipt
20 of the additional information, the organization shall pay the
21 claim within 10 days. If the claim is submitted by United
22 States mail or overnight delivery service, the organization
23 shall pay the claim within 30 days or the organization shall
24 advise the subscriber of what additional information is
25 required to adjudicate the claim. After receipt of the
26 additional information, the organization shall pay the claim
27 within 10 days. If the organization fails to pay claims
28 submitted by subscribers within the time periods specified in
29 this paragraph, the organization shall pay the subscriber
30 twice the amount of the claim. Failure to pay claims and
31 penalties, if applicable, within the time periods specified in
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1 this paragraph, is a violation of the insurance code and each
2 occurrence shall be considered a separate violation.
3 Section 9. Effective October 16, 2002, subsection (1)
4 of section 641.30, Florida Statutes, is amended to read:
5 641.30 Construction and relationship to other laws.--
6 (1) Every health maintenance organization shall accept
7 the standard health claim form prescribed pursuant to s.
8 641.3155 627.647.
9 Section 10. Effective October 16, 2002, section
10 641.3155, Florida Statutes, is amended to read:
11 641.3155 Payment of claims.--
12 (1)(a) As used in this section, the term "clean claim"
13 for a noninstitutional provider means a paper or electronic
14 billing instrument that consists of the HCFA 1500 data set
15 that has all mandatory entries for a physician licensed under
16 chapter 458 or chapter 459 or other appropriate form for any
17 other noninstitutional provider, or its successor. For
18 institutional providers, "claim" means a paper or electronic
19 billing instrument that consists of the UB-92 data set or its
20 successor that has all mandatory entries. claim submitted on a
21 HCFA 1500 form which has no defect or impropriety, including
22 lack of required substantiating documentation for
23 noncontracted providers and suppliers, or particular
24 circumstances requiring special treatment which prevent timely
25 payment from being made on the claim. A claim may not be
26 considered not clean solely because a health maintenance
27 organization refers the claim to a medical specialist within
28 the health maintenance organization for examination. If
29 additional substantiating documentation, such as the medical
30 record or encounter data, is required from a source outside
31 the health maintenance organization, the claim is considered
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1 not clean. This definition of "clean claim" is repealed on the
2 effective date of rules adopted by the department which define
3 the term "clean claim."
4 (b) Absent a written definition that is agreed upon
5 through contract, the term "clean claim" for an institutional
6 claim is a properly and accurately completed paper or
7 electronic billing instrument that consists of the UB-92 data
8 set or its successor with entries stated as mandatory by the
9 National Uniform Billing Committee.
10 (b)(c) The department shall adopt rules to establish
11 claim forms consistent with federal claim-filing standards for
12 health maintenance organizations required by the Secretary of
13 the United States Department of Health and Human Services
14 federal Health Care Financing Administration. The department
15 shall may adopt rules to require code sets consistent with
16 code sets adopted by the Secretary of the United States
17 Department of Health and Human Services. The code sets shall
18 apply to electronic claims. A code set, as defined by the
19 secretary, shall include both the codes and the descriptors of
20 the codes and shall also include, but not be limited to:
21 1. Medical data code sets, including the International
22 Classification of Diseases, the HCFA Common Procedure Coding
23 System and current procedure terminology, and the HCFA Common
24 Procedure Coding System for supplies or other items used in
25 health care services.
26 2. Health care claims or equivalent encounter
27 information for professional and institutional health care
28 claims.
29 3. Eligibility for a health plan standard.
30 4. Referral certification and authorization standard.
31 5. Health care claim status standard.
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1 6. Health care payment and remittance advice standard.
2 7. Enrollment and disenrollment in a health plan
3 standard.
4 8. Coordination of benefits standard.
5 9. Revenue codes used by Medicare for processing
6 claims.
7 10. National Correct Coding Initiative edits used by
8 Medicare relating to coding standards consistent with Medicare
9 coding standards adopted by the federal Health Care Financing
10 Administration.
11 (c) All providers and payors shall use the standard
12 code sets defined for their area of operation by the Secretary
13 of the United States Department of Health and Human Services
14 for the filing and adjudication of electronic claims. The
15 version of the code set shall be the version that is valid at
16 the time the health care is furnished, defined as the date of
17 discharge for inpatient services and date of service for
18 health care provided in an outpatient or ambulatory setting.
19 (2)(a) A health maintenance organization shall pay any
20 clean claim or any portion of a clean claim made by a contract
21 provider for services or goods provided under a contract with
22 the health maintenance organization or a clean claim made by a
23 noncontract provider which the organization does not contest
24 or deny, within 15 35 days after receipt of the claim by the
25 health maintenance organization which is mailed or
26 electronically submitted transferred by the provider, or
27 within 35 calendar days after receipt of the claim by the
28 health maintenance organization that is submitted by the
29 provider using either hand delivery, the United States mail,
30 or a reputable overnight delivery service. The investigation
31 and determination of eligibility for payment, including any
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1 coordination of any other payments, does not extend the time
2 periods contained in this paragraph.
3 (b) A health maintenance organization that denies or
4 contests a provider's claim or any portion of a claim shall
5 notify the provider, in writing, within 35 calendar days after
6 the health maintenance organization receives the claim, if
7 submitted by hand delivery, United States mail, or overnight
8 delivery service, or within 15 calendar days after the health
9 maintenance organization receives the claim if submitted by
10 electronic means, that the claim is contested or denied. The
11 notice that the claim is denied or contested must identify the
12 contested portion of the claim and the specific reason for
13 contesting or denying the claim, and, if contested, must give
14 the provider a written itemization of any include a request
15 for additional information or additional documents needed to
16 process the claim or any portion of the claim that is not
17 being paid. If the provider submits additional information,
18 the provider must, within 35 days after receipt of the
19 request, mail or electronically transfer the information to
20 the health maintenance organization. The health maintenance
21 organization shall pay or deny the claim or portion of the
22 claim within 35 calendar 45 days after receipt of the
23 information from the provider. A health maintenance
24 organization may not make more than one request under this
25 paragraph in connection with a claim, unless the provider
26 fails to submit all of the requested information to process
27 the claim, in which case the health maintenance organization
28 may provide the health care provider with one additional
29 opportunity to submit the additional information needed to
30 process the claim.
31
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1 (c) If a health maintenance organization requests
2 additional information or additional documents from a person
3 other than the provider who submitted the claim, the health
4 maintenance organization shall provide a copy of the request
5 to the provider who submitted the claim. The health
6 maintenance organization shall not withhold payment pending
7 receipt of information or documents requested under this
8 paragraph. If, upon receiving information or documents
9 requested under this paragraph, the health maintenance
10 organization determines the existence of an error in payment
11 of the claim, the health maintenance organization may recover
12 the payment under subsection (5).
13 (d) A health maintenance organization shall not deny
14 or withhold payment on a claim because the insured has not
15 paid a requested deductible or copayment.
16 (3) Payment of a claim is considered made on the date
17 the payment was received or electronically transferred or
18 otherwise delivered. An insurer that does not pay a claim when
19 payment is due as provided in subsection (4) shall pay the
20 provider submitting the claim the full amount of the
21 provider's billed charges submitted on the claim or twice the
22 provider's contracted rate, whichever is less. An overdue
23 payment of a claim bears simple interest at the rate of 10
24 percent per year. Interest on an overdue payment for a clean
25 claim or for any uncontested portion of a clean claim begins
26 to accrue on the 36th day after the claim has been received.
27 The interest is payable with the payment of the claim.
28 (4) A health maintenance organization shall pay or
29 deny any claim no later than 50 calendar 120 days after
30 receiving the claim if the claim is submitted electronically
31 or no later than 70 calendar days if the claim is submitted by
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1 hand delivery, United States mail, or a reputable overnight
2 delivery service. Failure to pay or deny a claim within such
3 time periods do so creates an uncontestable obligation for the
4 health maintenance organization to pay the claim to the
5 provider. The running of the time specified in this subsection
6 shall be tolled by the number of days taken by the provider
7 who submitted the claim to submit the additional information
8 requested by the health maintenance organization pursuant to
9 paragraph (2)(b).
10 (5)(a) If, as a result of retroactive review of
11 coverage decisions or payment levels, a health maintenance
12 organization determines that it has made an overpayment to a
13 provider for services rendered to a subscriber, the
14 organization must make a claim for such overpayment. The
15 organization may not reduce payment to that provider for other
16 services unless the provider agrees to the reduction in
17 writing after receipt of the claim for overpayment from the
18 health maintenance organization or fails to respond to the
19 organization's claim as required in this subsection.
20 (b) A provider shall pay a claim for an overpayment
21 made by a health maintenance organization which the provider
22 does not contest or deny within 15 calendar 35 days after
23 receipt of the claim that is mailed or electronically
24 transferred to the provider, or within 35 calendar days after
25 receipt of the claim that is submitted to the provider using
26 either United States mail or a reputable overnight delivery
27 service.
28 (c) A provider that denies or contests an
29 organization's claim for overpayment or any portion of a claim
30 shall notify the organization, in writing, within 35 calendar
31 days after the provider receives the claim if the claim is
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1 submitted by United States mail or overnight delivery service,
2 or within 15 calendar days after the provider receives the
3 claim if the claim is electronically transferred to the
4 provider, that the claim for overpayment is contested or
5 denied. The notice that the claim for overpayment is denied or
6 contested must identify the contested portion of the claim and
7 the specific reason for contesting or denying the claim, and,
8 if contested, must include a request for additional
9 information. If the organization submits additional
10 information, the organization must, within 21 calendar 35 days
11 after receipt of the request, mail or electronically transfer
12 the information to the provider. The provider shall pay or
13 deny the claim for overpayment within 30 calendar 45 days
14 after receipt of the information.
15 (d) Payment of a claim for overpayment is considered
16 made on the date payment was received or electronically
17 transferred or otherwise delivered to the organization, or the
18 date that the provider receives a payment from the
19 organization that reduces or deducts the overpayment. An
20 overdue payment of a claim bears simple interest at the rate
21 of 18 10 percent a year. Interest on an overdue payment of a
22 claim for overpayment or for any uncontested portion of a
23 claim for overpayment begins to accrue on the 36th day after
24 the claim for overpayment has been received.
25 (e) A provider shall pay or deny any claim for
26 overpayment no later than 71 calendar 120 days after receiving
27 the claim if submitted electronically or no later than 91
28 calendar days if the claim for overpayment is submitted by
29 United States mail or overnight delivery service. Failure to
30 do so creates an uncontestable obligation for the provider to
31 pay the claim to the organization.
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1 (6) Any retroactive reductions of payments or demands
2 for refund of previous overpayments which are due to
3 retroactive review-of-coverage decisions or payment levels
4 must be reconciled to specific claims unless the parties agree
5 to other reconciliation methods and terms. Any retroactive
6 demands by providers for payment due to underpayments or
7 nonpayments for covered services must be reconciled to
8 specific claims unless the parties agree to other
9 reconciliation methods and terms. The look-back or audit
10 review period shall not exceed 1 year may be specified by the
11 terms of the contract.
12 (7)(a) A provider claim for payment shall be
13 considered received by the health maintenance organization
14 when receipt is verified electronically, if the claim has been
15 electronically transmitted to the health maintenance
16 organization, on the date indicated on the return receipt when
17 receipt is verified electronically or, if the claim is mailed
18 by United States mail to the address disclosed by the
19 organization, or on the date the delivery receipt is signed by
20 the health maintenance organization if the claim is hand
21 delivered on the date indicated on the return receipt. A
22 health maintenance organization shall not require a provider
23 to resubmit a claim for payment if the claim has been received
24 by the organization. A provider must wait 45 calendar days
25 following receipt of a claim before submitting a duplicate
26 claim.
27 (b) A health maintenance organization claim for
28 overpayment shall be considered received by a provider, if the
29 claim has been electronically transmitted to the provider,
30 when receipt is verified electronically or, if the claim is
31 mailed to the address disclosed by the provider, on the date
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1 indicated on the return receipt. A provider shall not require
2 a health maintenance organization to resubmit a claim for
3 payment if the claim for overpayment has been received by the
4 provider. An organization must wait 45 calendar days following
5 the provider's receipt of a claim for overpayment before
6 submitting a duplicate claim.
7 (c) This section does not preclude the health
8 maintenance organization and provider from agreeing to other
9 methods of transmission and receipt of claims.
10 (8) A health maintenance organization shall provide a
11 provider, or the provider's designee who bills electronically,
12 electronic acknowledgment of the receipt of a claim within 24
13 hours after receipt. A provider, or the provider's designee,
14 who bills electronically is entitled to electronic
15 acknowledgment of the receipt of a claim within 72 hours.
16 (9) A health maintenance organization may not
17 retroactively deny a claim because of subscriber ineligibility
18 more than 1 year after the date of payment of the clean claim.
19 (10) A health maintenance organization shall pay a
20 contracted primary care or admitting physician, pursuant to
21 such physician's contract, for providing inpatient services in
22 a contracted hospital to a subscriber, if such services are
23 determined by the organization to be medically necessary and
24 covered services under the organization's contract with the
25 contract holder.
26 (11)(a) Each policy issued by a health maintenance
27 organization shall contain a provision for coordinating
28 benefits under the policy with any similar benefits provided
29 by any other health maintenance organization, group hospital,
30 medical, or surgical expense policy; any group health care
31 services plan; any auto medical policy; any governmental
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1 medical expense policy; or any group-type self-insurance plan
2 that provides protection or insurance against hospital,
3 medical, or surgical expenses for the same loss.
4 (b) A policy issued by a health maintenance
5 organization shall contain a provision whereby the health
6 maintenance organization may reduce or refuse to pay benefits
7 otherwise payable under the policy solely due to the existence
8 of similar benefits provided under insurance policies issued
9 by the same or another health maintenance organization,
10 insurer, health care services plan, or self-insurance plan if
11 the similar benefits provide protection or insurance against
12 hospital, medical, or surgical expenses only if, as a
13 condition of coordinating benefits with another insurer, 100
14 percent of the total covered changes described in the policies
15 and presented for payment are paid.
16 (c) If a subscriber fails to furnish the provider with
17 the correct name and address of the subscriber's primary
18 prepaid health plan, group hospital, medical, or surgical
19 expense policy, group health care services plan, or group-type
20 self-insurance plan that provides protection or insurance
21 against hospital, medical, or surgical expenses delivered or
22 issued for delivery in this state, and the claim is submitted
23 to a secondary prepaid health plan or insurer and is
24 subsequently rejected, the provider has 60 calendar days from
25 the date the provider obtains the correct billing information
26 for the primary or secondary insurer or prepaid health plan to
27 submit the claim, regardless of any time periods for
28 submission of claims established by any applicable contract.
29 For the purposes of this subsection, "insurer" includes
30 persons contracting with preferred provider networks pursuant
31
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1 to s. 627.6471 and exclusive provider networks pursuant to s.
2 627.6472.
3 (12)(a) Without regard to any other remedy or relief
4 to which a provider is entitled, any provider aggrieved by a
5 violation of this section by a health maintenance organization
6 may bring an action to enjoin a person who has violated, or is
7 violating, this section. In any such action, the provider who
8 has suffered a loss as a result of the violation may recover
9 any amounts due the provider by the health maintenance
10 organization, including accrued interest, plus attorney's fees
11 and costs as provided in paragraph (b).
12 (b) In any action arising out of a violation of this
13 section by a health maintenance organization in which the
14 health maintenance organization is found to have violated this
15 section, the provider, after judgment in the trial court and
16 after exhausting all appeals, if any, shall receive his or her
17 reasonable attorney's fees and costs from the health
18 maintenance organization.
19 (13) The provisions of this section may not be waived,
20 voided, or nullified by contract.
21 Section 11. Section 641.3156, Florida Statutes, is
22 amended to read:
23 641.3156 Treatment authorization; payment of claims.--
24 (1) For purposes of this section, "authorization"
25 includes any requirement of a provider to notify a health
26 maintenance organization in advance of providing a covered
27 service, regardless of whether the actual terminology used by
28 the organization includes, but is not limited to,
29 preauthorization, precertification, notification, or any other
30 similar terminology.
31
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1 (2) A health maintenance organization that requires
2 authorization for medical care and health care services shall
3 provide to each contracted provider at the time a contract is
4 signed a list of the medical care and health care services
5 that require authorization and the authorization procedures
6 used by the organization. A health maintenance organization
7 that requires authorization for medical care and health care
8 services shall provide to each noncontracted provider, not
9 later than 10 working days after a request is made, a list of
10 the medical care and health care services that require
11 authorization and the authorization procedures used by the
12 organization. The list of medical care or health care services
13 that require authorization and the authorization procedures
14 used by the organization shall not be modified unless written
15 notice is provided at least 30 days in advance of any changes
16 to all subscribers, contracted providers, and noncontracted
17 providers who had previously requested a list of medical care
18 or health care services that require authorization.
19 (3) Any claim for treatment that does not require an
20 authorization for a covered service that is ordered by a
21 contracted physician may not be denied. A health maintenance
22 organization must pay any hospital-service or referral-service
23 claim for treatment for an eligible subscriber which was
24 authorized by a provider empowered by contract with the health
25 maintenance organization to authorize or direct the patient's
26 utilization of health care services and which was also
27 authorized in accordance with the health maintenance
28 organization's current and communicated procedures, unless the
29 provider provided information to the health maintenance
30 organization with the willful intention to misinform the
31 health maintenance organization.
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1 (4)(a)(2) A claim for treatment may not be denied if a
2 provider follows the health maintenance organization's
3 authorization procedures and receives authorization for a
4 covered service for an eligible subscriber, unless the
5 provider provided information to the health maintenance
6 organization with the willful intention to misinform the
7 health maintenance organization.
8 (b) On receipt of a request from a provider for
9 authorization pursuant to this section, the health maintenance
10 organization shall issue a determination indicating whether
11 the service or services are authorized. The determination must
12 be transmitted to the provider making the request in writing
13 no later than 8 hours after the request is made by the
14 provider. If the organization denies the request for an
15 authorization, the health maintenance organization must notify
16 the subscriber at the same time when notifying the provider
17 requesting the authorization. A health maintenance
18 organization that fails to respond to a request for an
19 authorization from a provider pursuant to this paragraph is
20 considered to have authorized the requested medical care or
21 health care service and payment may not be denied.
22 (5) If the proposed medical care or health care
23 service or services involve an inpatient admission and the
24 health maintenance organization requires authorization as a
25 condition of payment, the health maintenance organization
26 shall issue a written or electronic authorization for the
27 total estimated length of stay for the admission. If the
28 proposed medical care or health care service or services are
29 to be provided to a patient who is an inpatient in a health
30 care facility at the time the services are proposed and the
31 medical care or health care service requires an authorization,
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1 the health maintenance organization shall issue a
2 determination indicating whether the proposed services are
3 authorized no later than 1 hour after the request by the
4 health care provider. A health maintenance organization that
5 fails to respond to such request within 1 hour is considered
6 to have authorized the requested medical care or health care
7 service and payment may not be denied.
8 (6)(3) Emergency services are subject to the
9 provisions of s. 641.513 and are not subject to the provisions
10 of this section, including any inpatient admission required in
11 order to stabilize the patient pursuant to federal and state
12 law.
13 (7) The provisions of this section may not be waived,
14 voided, or nullified by contract.
15 Section 12. Subsection (4) of section 627.651, Florida
16 Statutes, is amended to read:
17 627.651 Group contracts and plans of self-insurance
18 must meet group requirements.--
19 (4) This section does not apply to any plan which is
20 established or maintained by an individual employer in
21 accordance with the Employee Retirement Income Security Act of
22 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
23 arrangement as defined in s. 624.437(1), except that a
24 multiple-employer welfare arrangement shall comply with ss.
25 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612,
26 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(9)(6).
27 This subsection does not allow an authorized insurer to issue
28 a group health insurance policy or certificate which does not
29 comply with this part.
30 Section 13. Effective October 16, 2002, section
31 627.647, Florida Statutes, is repealed.
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1 Section 14. Except as otherwise provided in this act,
2 this act shall take effect October 1, 2002.
3
4 *****************************************
5 LEGISLATIVE SUMMARY
6
Includes preferred provider organizations within the
7 definition of managed care organization and provides for
filing unresolved internal dispute-resolution processes
8 with a dispute-resolution organization. Provides for
coordination of benefits under multiple health insurance
9 policies regardless of time periods. Revises time of
payment of claims provisions. Requires the Department of
10 Insurance to adopt insurance claim-filing rules
consistent with federal standards and provides
11 requirements and procedures for payment or denial of
claims. Entitles insureds and health maintenance
12 organization subscribers to prompt payment of claims for
covered services. Requires health insurers and health
13 maintenance organizations to provide lists of medical
care and health care services that require authorization
14 and provides procedural requirements for determination
and issuance of authorizations for services. Revises
15 limitations on policies providing differing schedules of
payments for preferred provider services and nonpreferred
16 provider services. Applies coordination of benefits,
payment of claims, and treatment authorizations
17 provisions to group, blanket, and franchise health
insurance. (See bill for details.)
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