Florida Senate - 2010                                    SB 1232
       
       
       
       By Senator Fasano
       
       
       
       
       11-00578B-10                                          20101232__
    1                        A bill to be entitled                      
    2         An act relating to health services claims; amending s.
    3         627.6141, F.S.; authorizing appeals from denials of
    4         certain claims for certain services; requiring a
    5         health insurer to conduct a retrospective review of
    6         the medical necessity of a service under certain
    7         circumstances; requiring the health insurer to submit
    8         a written justification for a determination that a
    9         service was not medically necessary and provide a
   10         process for appealing the determination; amending s.
   11         641.3156, F.S.; authorizing appeals from denials of
   12         certain claims for certain services; requiring a
   13         health maintenance organization to conduct a
   14         retrospective review of the medical necessity of a
   15         service under certain circumstances; requiring the
   16         health maintenance organization to submit a written
   17         justification for a determination that a service was
   18         not medically necessary and provide a process for
   19         appealing the determination; providing an effective
   20         date.
   21  
   22  Be It Enacted by the Legislature of the State of Florida:
   23  
   24         Section 1. Section 627.6141, Florida Statutes, is amended
   25  to read:
   26         627.6141 Denial of claims.—Each claimant, or provider
   27  acting for a claimant, who has had a claim denied or a portion
   28  of a claim denied because the provider failed to obtain the
   29  necessary authorization due to an unintentional act or error or
   30  omission as not medically necessary must be provided an
   31  opportunity for an appeal to the insurer’s licensed physician
   32  who is responsible for the medical necessity reviews under the
   33  plan or is a member of the plan’s peer review group. If the
   34  provider appeals the denial, the health insurer shall conduct
   35  and complete a retrospective review of the medical necessity of
   36  the service within 30 business days after the submitted appeal.
   37  If the insurer determines upon review that the service was
   38  medically necessary, the insurer shall reverse the denial and
   39  pay the claim. If the insurer determines that the service was
   40  not medically necessary, the insurer shall submit to the
   41  provider specific written clinical justification for the
   42  determination. The appeal may be by telephone, and the insurer’s
   43  licensed physician must respond within a reasonable time, not to
   44  exceed 15 business days.
   45         Section 2. Subsection (3) of section 641.3156, Florida
   46  Statutes, is renumbered as subsection (4), and a new subsection
   47  (3) is added to that section to read:
   48         641.3156 Treatment authorization; payment of claims.—
   49         (3) If a provider claim or a portion of a provider claim is
   50  denied because the provider, due to an unintentional act of
   51  error or omission, failed to obtain the necessary authorization,
   52  the provider may appeal the denial to the health maintenance
   53  organization’s licensed physician who is responsible for medical
   54  necessity reviews. The health maintenance organization shall
   55  conduct and complete a retrospective review of the medical
   56  necessity of the service within 30 business days after the
   57  submitted appeal. If the health maintenance organization
   58  determines that the service is medically necessary, the health
   59  maintenance organization shall reverse the denial and pay the
   60  claim. If the health maintenance organization determines that
   61  the service is not medically necessary, the health maintenance
   62  organization shall provide the provider with specific written
   63  clinical justification for the determination.
   64         Section 3. This act shall take effect July 1, 2010.