HB 715

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

CODING: Words stricken are deletions; words underlined are additions.