1

The Committee on Health Policy (Dockery) recommended the

2

following amendment:

3

4

     Senate Amendment (with directory and title amendments)

5

     Delete line(s) 154-211

6

and insert:

7

     Section 6.  Subsections (2) and (5) of section 641.3155,

8

Florida Statutes, are amended to read:

9

     641.3155  Prompt payment of claims.--

10

     (2) All claims for payment, underpayment, or overpayment,

11

whether electronic or nonelectronic:

12

     (a)  Are considered received on the date the claim is

13

received by the organization at its designated claims-receipt

14

location or the date a claim for overpayment is received by the

15

provider at its designated location.

16

     (b)  Must be mailed or electronically transferred to the

17

primary organization within 60 days 6 months after the following

18

have occurred:

19

     1.  Discharge for inpatient services or the date of service

20

for outpatient services; and

21

     2.  The provider has been furnished with the correct name

22

and address of the patient's health maintenance organization.

23

24

All claims for payment, whether electronic or nonelectronic, must

25

be mailed or electronically transferred to the secondary

26

organization within 90 days after final determination by the

27

primary organization. A provider's claim is considered submitted

28

on the date it is electronically transferred or mailed.

29

     (c)  Must not duplicate a claim previously submitted unless

30

it is determined that the original claim was not received or is

31

otherwise lost.

32

     (5)  If a health maintenance organization determines that it

33

has made an overpayment to a provider for services rendered to a

34

subscriber, the health maintenance organization must make a claim

35

for such overpayment to the provider's designated location. A

36

health maintenance organization that makes a claim for

37

overpayment to a provider under this section shall give the

38

provider a written or electronic statement specifying the basis

39

for the retroactive denial or payment adjustment. The health

40

maintenance organization must identify the claim or claims, or

41

overpayment claim portion thereof, for which a claim for

42

overpayment is submitted.

43

     (a)  If an overpayment determination is the result of

44

retroactive review or audit of coverage decisions or payment

45

levels not related to fraud, a health maintenance organization

46

shall adhere to the following procedures:

47

     1.  All claims for overpayment must be submitted to a

48

provider within 18 30 months after the health maintenance

49

organization's payment of the claim. A provider must pay, deny,

50

or contest the health maintenance organization's claim for

51

overpayment within 40 days after the receipt of the claim. All

52

contested claims for overpayment must be paid or denied within

53

120 days after receipt of the claim. Failure to pay or deny

54

overpayment and claim within 140 days after receipt creates an

55

uncontestable obligation to pay the claim.

56

     2.  A provider that denies or contests a health maintenance

57

organization's claim for overpayment or any portion of a claim

58

shall notify the organization, in writing, within 35 days after

59

the provider receives the claim that the claim for overpayment is

60

contested or denied. The notice that the claim for overpayment is

61

denied or contested must identify the contested portion of the

62

claim and the specific reason for contesting or denying the claim

63

and, if contested, must include a request for additional

64

information. If the organization submits additional information,

65

the organization must, within 35 days after receipt of the

66

request, mail or electronically transfer the information to the

67

provider. The provider shall pay or deny the claim for

68

overpayment within 45 days after receipt of the information. The

69

notice is considered made on the date the notice is mailed or

70

electronically transferred by the provider.

71

     3.  The health maintenance organization may not reduce

72

payment to the provider for other services unless the provider

73

agrees to the reduction in writing or fails to respond to the

74

health maintenance organization's overpayment claim as required

75

by this paragraph.

76

     4.  Payment of an overpayment claim is considered made on

77

the date the payment was mailed or electronically transferred. An

78

overdue payment of a claim bears simple interest at the rate of

79

12 percent per year. Interest on an overdue payment for a claim

80

for an overpayment payment begins to accrue when the claim should

81

have been paid, denied, or contested.

82

     (b) A claim for underpayment by a provider or overpayment

83

by a health maintenance organization may shall not be made

84

permitted beyond 18 30 months after the health maintenance

85

organization's payment of a claim, except that claims for

86

overpayment may be sought beyond that time from providers

87

convicted of fraud pursuant to s. 817.234 or where fraud or abuse

88

is suspected.

89

90

================ T I T L E  A M E N D M E N T ================

91

And the title is amended as follows:

92

     Delete line(s) 27-29

93

and insert:

94

641.3155, F.S.; decreasing the amount of time in which all

95

claims for payment, underpayment, or overpayment must be

96

mailed or electronically transferred; decreasing the

97

amount of time in which a health maintenance organization

98

may make a claim for overpayment or underpayment against a

99

provider; providing an exception; providing for

100

applicability;

4/1/2008  10:53:00 AM     15-06300-08