Florida Senate - 2021 SB 1386
By Senator Harrell
25-01242A-21 20211386__
1 A bill to be entitled
2 An act relating to overpayment of claims; amending ss.
3 627.6131 and 641.3155, F.S.; revising the timeframe
4 for submission of insurer and health maintenance
5 organization claims, respectively, for overpayment to
6 providers; conforming provisions to changes made by
7 the act; providing an effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. Subsections (6) and (18) of section 627.6131,
12 Florida Statutes, are amended to read:
13 627.6131 Payment of claims.—
14 (6) If a health insurer determines that it has made an
15 overpayment to a provider for services rendered to an insured,
16 the health insurer must make a claim for such overpayment to the
17 provider’s designated location. A health insurer that makes a
18 claim for overpayment to a provider under this section shall
19 give the provider a written or electronic statement specifying
20 the basis for the retroactive denial or payment adjustment. The
21 insurer must identify the claim or claims, or overpayment claim
22 portion thereof, for which a claim for overpayment is submitted.
23 (a) If an overpayment determination is the result of
24 retroactive review or audit of coverage decisions or payment
25 levels not related to fraud, a health insurer shall adhere to
26 the following procedures:
27 1. All claims for overpayment must be submitted to a
28 provider within 12 30 months after the health insurer’s payment
29 of the claim. A provider must pay, deny, or contest the health
30 insurer’s claim for overpayment within 40 days after the receipt
31 of the claim. All contested claims for overpayment must be paid
32 or denied within 120 days after receipt of the claim. Failure to
33 pay or deny overpayment and claim within 140 days after receipt
34 creates an uncontestable obligation to pay the claim.
35 2. A provider that denies or contests a health insurer’s
36 claim for overpayment or any portion of a claim shall notify the
37 health insurer, in writing, within 35 days after the provider
38 receives the claim that the claim for overpayment is contested
39 or denied. The notice that the claim for overpayment is denied
40 or contested must identify the contested portion of the claim
41 and the specific reason for contesting or denying the claim and,
42 if contested, must include a request for additional information.
43 If the health insurer submits additional information, the health
44 insurer must, within 35 days after receipt of the request, mail
45 or electronically transfer the information to the provider. The
46 provider shall pay or deny the claim for overpayment within 45
47 days after receipt of the information. The notice is considered
48 made on the date the notice is mailed or electronically
49 transferred by the provider.
50 3. The health insurer may not reduce payment to the
51 provider for other services unless the provider agrees to the
52 reduction in writing or fails to respond to the health insurer’s
53 overpayment claim as required by this paragraph.
54 4. Payment of an overpayment claim is considered made on
55 the date the payment was mailed or electronically transferred.
56 An overdue payment of a claim bears simple interest at the rate
57 of 12 percent per year. Interest on an overdue payment for a
58 claim for an overpayment begins to accrue when the claim should
59 have been paid, denied, or contested.
60 (b) A claim for overpayment shall not be permitted beyond
61 30 months after the health insurer’s payment of a claim, except
62 that Claims for overpayment may be sought beyond the 12-month
63 period provided in this subsection that time from providers
64 convicted of fraud pursuant to s. 817.234.
65 (18) Notwithstanding the 30-month period provided in
66 subsection (6), all claims for overpayment submitted to a
67 provider licensed under chapter 458, chapter 459, chapter 460,
68 chapter 461, or chapter 466 must be submitted to the provider
69 within 12 months after the health insurer’s payment of the
70 claim. A claim for overpayment may not be permitted beyond 12
71 months after the health insurer’s payment of a claim, except
72 that claims for overpayment may be sought beyond that time from
73 providers convicted of fraud pursuant to s. 817.234.
74 Section 2. Subsections (5) and (16) of section 641.3155,
75 Florida Statutes, are amended to read:
76 641.3155 Prompt payment of claims.—
77 (5) If a health maintenance organization determines that it
78 has made an overpayment to a provider for services rendered to a
79 subscriber, the health maintenance organization must make a
80 claim for such overpayment to the provider’s designated
81 location. A health maintenance organization that makes a claim
82 for overpayment to a provider under this section shall give the
83 provider a written or electronic statement specifying the basis
84 for the retroactive denial or payment adjustment. The health
85 maintenance organization must identify the claim or claims, or
86 overpayment claim portion thereof, for which a claim for
87 overpayment is submitted.
88 (a) If an overpayment determination is the result of
89 retroactive review or audit of coverage decisions or payment
90 levels not related to fraud, a health maintenance organization
91 shall adhere to the following procedures:
92 1. All claims for overpayment must be submitted to a
93 provider within 12 30 months after the health maintenance
94 organization’s payment of the claim. A provider must pay, deny,
95 or contest the health maintenance organization’s claim for
96 overpayment within 40 days after the receipt of the claim. All
97 contested claims for overpayment must be paid or denied within
98 120 days after receipt of the claim. Failure to pay or deny
99 overpayment and claim within 140 days after receipt creates an
100 uncontestable obligation to pay the claim.
101 2. A provider that denies or contests a health maintenance
102 organization’s claim for overpayment or any portion of a claim
103 shall notify the organization, in writing, within 35 days after
104 the provider receives the claim that the claim for overpayment
105 is contested or denied. The notice that the claim for
106 overpayment is denied or contested must identify the contested
107 portion of the claim and the specific reason for contesting or
108 denying the claim and, if contested, must include a request for
109 additional information. If the organization submits additional
110 information, the organization must, within 35 days after receipt
111 of the request, mail or electronically transfer the information
112 to the provider. The provider shall pay or deny the claim for
113 overpayment within 45 days after receipt of the information. The
114 notice is considered made on the date the notice is mailed or
115 electronically transferred by the provider.
116 3. The health maintenance organization may not reduce
117 payment to the provider for other services unless the provider
118 agrees to the reduction in writing or fails to respond to the
119 health maintenance organization’s overpayment claim as required
120 by this paragraph.
121 4. Payment of an overpayment claim is considered made on
122 the date the payment was mailed or electronically transferred.
123 An overdue payment of a claim bears simple interest at the rate
124 of 12 percent per year. Interest on an overdue payment for a
125 claim for an overpayment payment begins to accrue when the claim
126 should have been paid, denied, or contested.
127 (b) A claim for overpayment shall not be permitted beyond
128 30 months after the health maintenance organization’s payment of
129 a claim, except that Claims for overpayment may be sought beyond
130 the 12-month period provided in this subsection that time from
131 providers convicted of fraud pursuant to s. 817.234.
132 (16) Notwithstanding the 30-month period provided in
133 subsection (5), all claims for overpayment submitted to a
134 provider licensed under chapter 458, chapter 459, chapter 460,
135 chapter 461, or chapter 466 must be submitted to the provider
136 within 12 months after the health maintenance organization’s
137 payment of the claim. A claim for overpayment may not be
138 permitted beyond 12 months after the health maintenance
139 organization’s payment of a claim, except that claims for
140 overpayment may be sought beyond that time from providers
141 convicted of fraud pursuant to s. 817.234.
142 Section 3. This act shall take effect July 1, 2021.