Florida Senate - 2024 SB 892
By Senator Harrell
31-00708-24 2024892__
1 A bill to be entitled
2 An act relating to dental insurance claims; amending
3 s. 627.6131, F.S.; prohibiting a contract between a
4 health insurer and a dentist from containing certain
5 restrictions on payment methods; requiring a health
6 insurer to make certain notifications before paying a
7 claim to a dentist through electronic funds transfer;
8 prohibiting a health insurer from charging a fee to
9 transmit a payment to a dentist through ACH transfer
10 unless the dentist has consented to such fee;
11 authorizing a health insurer to charge reasonable fees
12 for other value-added services related to the ACH
13 transfer; providing construction; authorizing the
14 Office of Insurance Regulation of the Financial
15 Services Commission to enforce certain provisions;
16 authorizing the commission to adopt rules; prohibiting
17 a health insurer from denying claims for procedures
18 included in a prior authorization; providing
19 exceptions; providing construction; authorizing the
20 office to enforce certain provisions; authorizing the
21 commission to adopt rules; amending s. 627.6474, F.S.;
22 revising the definition of the term “covered
23 services”; amending s. 636.032, F.S.; prohibiting a
24 contract between a prepaid limited health service
25 organization and a dentist from containing certain
26 restrictions on payment methods; requiring the prepaid
27 limited health service organization to make certain
28 notifications before paying a claim to a dentist
29 through electronic funds transfer; prohibiting a
30 prepaid limited health service organization from
31 charging a fee to transmit a payment to a dentist
32 through ACH transfer unless the dentist has consented
33 to such fee; authorizing the prepaid limited health
34 service organization to charge reasonable fees for
35 other value-added services related to the ACH
36 transfer; providing construction; authorizing the
37 office to enforce certain provisions; authorizing the
38 commission to adopt rules; amending s. 636.035, F.S.;
39 revising the definition of the term “covered
40 services”; prohibiting a prepaid limited health
41 service organization from denying claims for
42 procedures included in a prior authorization;
43 providing exceptions; providing construction;
44 authorizing the office to enforce certain provisions;
45 authorizing the commission to adopt rules; amending s.
46 641.315, F.S.; revising the definition of the term
47 “covered service”; prohibiting a contract between a
48 health maintenance organization and a dentist from
49 containing certain restrictions on payment methods;
50 requiring the health maintenance organization to make
51 certain notifications before paying a claim to a
52 dentist through electronic funds transfer; prohibiting
53 a health maintenance organization from charging a fee
54 to transmit a payment to a dentist through ACH
55 transfer unless the dentist has consented to such fee;
56 authorizing the health maintenance organization to
57 charge reasonable fees for other value-added services
58 related to the ACH transfer; providing construction;
59 authorizing the office to enforce certain provisions;
60 authorizing the commission to adopt rules; prohibiting
61 a health maintenance organization from denying claims
62 for procedures included in a prior authorization;
63 providing exceptions; providing construction;
64 authorizing the office to enforce certain provisions;
65 authorizing the commission to adopt rules; providing
66 an effective date.
67
68 Be It Enacted by the Legislature of the State of Florida:
69
70 Section 1. Subsections (20) and (21) are added to section
71 627.6131, Florida Statutes, to read:
72 627.6131 Payment of claims.—
73 (20)(a) A contract between a health insurer and a dentist
74 licensed under chapter 466 for the provision of services to an
75 insured may not specify credit card payment as the only
76 acceptable method for payments from the health insurer to the
77 dentist.
78 (b) At least 10 days before a health insurer pays a claim
79 to a dentist through electronic funds transfer, including, but
80 not limited to, virtual credit card payments, the health insurer
81 shall notify the dentist in writing of all of the following:
82 1. The fees, if any, associated with the electronic funds
83 transfer.
84 2. The available methods of payment of claims by the health
85 insurer, with clear instructions to the dentist on how to select
86 an alternative payment method.
87 (c) A health insurer that pays a claim to a dentist through
88 Automated Clearing House (ACH) transfer may not charge a fee
89 solely to transmit the payment to the dentist unless the dentist
90 has consented to the fee. A health insurer may charge reasonable
91 fees for other value-added services related to the ACH transfer,
92 including, but not limited to, transaction management, data
93 management, and portal services.
94 (d) This subsection may not be waived, voided, or nullified
95 by contract, and any contractual clause in conflict with this
96 subsection or which purports to waive any requirements of this
97 subsection is null and void.
98 (e) The office has all rights and powers to enforce this
99 subsection as provided by s. 624.307.
100 (f) The commission may adopt rules to implement this
101 subsection.
102 (21)(a) A health insurer may not deny any claim
103 subsequently submitted by a dentist licensed under chapter 466
104 for procedures specifically included in a prior authorization
105 unless at least one of the following circumstances applies for
106 each procedure denied:
107 1. Benefit limitations, such as annual maximums and
108 frequency limitations not applicable at the time of the prior
109 authorization, are reached subsequent to issuance of the prior
110 authorization.
111 2. The documentation provided by the person submitting the
112 claim fails to support the claim as originally authorized.
113 3. Subsequent to the issuance of the prior authorization,
114 new procedures are provided to the patient or a change in the
115 condition of the patient occurs such that the prior authorized
116 procedure would no longer be considered medically necessary,
117 based on the prevailing standard of care.
118 4. Subsequent to the issuance of the prior authorization,
119 new procedures are provided to the patient or a change in the
120 patient’s condition occurs such that the prior authorized
121 procedure would at that time have required disapproval pursuant
122 to the terms and conditions for coverage under the patient’s
123 plan in effect at the time the prior authorization was issued.
124 5. The denial of the claim was due to one of the following:
125 a. Another payor is responsible for payment.
126 b. The dentist has already been paid for the procedures
127 identified in the claim.
128 c. The claim was submitted fraudulently, or the prior
129 authorization was based in whole or material part on erroneous
130 information provided to the health insurer by the dentist,
131 patient, or other person not related to the insurer.
132 d. The person receiving the procedure was not eligible to
133 receive the procedure on the date of service and the health
134 insurer did not know, and with the exercise of reasonable care
135 could not have known, of his or her ineligibility.
136 (b) This subsection may not be waived, voided, or nullified
137 by contract, and any contractual clause in conflict with this
138 subsection or which purports to waive any requirements of this
139 subsection is null and void.
140 (c) The office has all rights and powers to enforce this
141 subsection as provided by s. 624.307.
142 (d) The commission may adopt rules to implement this
143 subsection.
144 Section 2. Subsection (2) of section 627.6474, Florida
145 Statutes, is amended to read:
146 627.6474 Provider contracts.—
147 (2) A contract between a health insurer and a dentist
148 licensed under chapter 466 for the provision of services to an
149 insured may not contain a provision that requires the dentist to
150 provide services to the insured under such contract at a fee set
151 by the health insurer unless such services are covered services
152 under the applicable contract. As used in this subsection, the
153 term “covered services” means dental care services for which a
154 reimbursement is available under the insured’s contract,
155 notwithstanding or for which a reimbursement would be available
156 but for the application of contractual limitations, such as
157 deductibles, coinsurance, waiting periods, annual or lifetime
158 maximums, frequency limitations, alternative benefit payments,
159 or any other limitation.
160 Section 3. Section 636.032, Florida Statutes, is amended to
161 read:
162 636.032 Acceptable payments.—
163 (1) Each prepaid limited health service organization may
164 accept from government agencies, corporations, groups, or
165 individuals payments covering all or part of the cost of
166 contracts entered into between the prepaid limited health
167 service organization and its subscribers.
168 (2)(a) A contract between a prepaid limited health service
169 organization and a dentist licensed under chapter 466 for the
170 provision of services to a subscriber may not specify credit
171 card payment as the only acceptable method for payments from the
172 prepaid limited health service organization to the dentist.
173 (b) At least 10 days before a limited health service
174 organization pays a claim to a dentist through electronic funds
175 transfer, including, but not limited to, virtual credit card
176 payments, the prepaid limited health service organization shall
177 notify the dentist in writing of all of the following:
178 1. The fees, if any, that are associated with the
179 electronic funds transfer.
180 2. The available methods of payment of claims by the
181 prepaid limited health service organization, with clear
182 instructions to the dentist on how to select an alternative
183 payment method.
184 (c) A prepaid limited health service organization that pays
185 a claim to a dentist through Automatic Clearing House (ACH)
186 transfer may not charge a fee solely to transmit the payment to
187 the dentist unless the dentist has consented to the fee. A
188 prepaid limited health service organization may charge
189 reasonable fees for other value-added services related to the
190 ACH transfer, including, but not limited to, transaction
191 management, data management, and portal services.
192 (d) This subsection may not be waived, voided, or nullified
193 by contract, and any contractual clause in conflict with this
194 subsection or which purports to waive any requirements of this
195 subsection is null and void.
196 (e) The office has all rights and powers to enforce this
197 subsection as provided by s. 624.307.
198 (f) The commission may adopt rules to implement this
199 subsection.
200 Section 4. Subsection (13) of section 636.035, Florida
201 Statutes, is amended, and subsection (15) is added to that
202 section, to read:
203 636.035 Provider arrangements.—
204 (13) A contract between a prepaid limited health service
205 organization and a dentist licensed under chapter 466 for the
206 provision of services to a subscriber of the prepaid limited
207 health service organization may not contain a provision that
208 requires the dentist to provide services to the subscriber of
209 the prepaid limited health service organization at a fee set by
210 the prepaid limited health service organization unless such
211 services are covered services under the applicable contract. As
212 used in this subsection, the term “covered services” means
213 dental care services for which a reimbursement is available
214 under the subscriber’s contract, notwithstanding or for which a
215 reimbursement would be available but for the application of
216 contractual limitations such as deductibles, coinsurance,
217 waiting periods, annual or lifetime maximums, frequency
218 limitations, alternative benefit payments, or any other
219 limitation.
220 (15)(a) A prepaid limited health service organization may
221 not deny any claim subsequently submitted by a dentist licensed
222 under chapter 466 for procedures specifically included in a
223 prior authorization unless at least one of the following
224 circumstances applies for each procedure denied:
225 1. Benefit limitations, such as annual maximums and
226 frequency limitations not applicable at the time of the prior
227 authorization, are reached subsequent to issuance of the prior
228 authorization.
229 2. The documentation provided by the person submitting the
230 claim fails to support the claim as originally authorized.
231 3. Subsequent to the issuance of the prior authorization,
232 new procedures are provided to the patient or a change in the
233 condition of the patient occurs such that the prior authorized
234 procedure would no longer be considered medically necessary,
235 based on the prevailing standard of care.
236 4. Subsequent to the issuance of the prior authorization,
237 new procedures are provided to the patient or a change in the
238 patient’s condition occurs such that the prior authorized
239 procedure would at that time have required disapproval pursuant
240 to the terms and conditions for coverage under the patient’s
241 plan in effect at the time the prior authorization was issued.
242 5. The denial of the dental service claim was due to one of
243 the following:
244 a. Another payor is responsible for payment.
245 b. The dentist has already been paid for the procedures
246 identified in the claim.
247 c. The claim was submitted fraudulently, or the prior
248 authorization was based in whole or material part on erroneous
249 information provided to the prepaid limited health service
250 organization by the dentist, patient, or other person not
251 related to the organization.
252 d. The person receiving the procedure was not eligible to
253 receive the procedure on the date of service and the prepaid
254 limited health service organization did not know, and with the
255 exercise of reasonable care could not have known, of his or her
256 ineligibility.
257 (b) This subsection may not be waived, voided, or nullified
258 by contract, and any contractual clause in conflict with this
259 subsection or which purports to waive any requirements of this
260 subsection is null and void.
261 (c) The office has all rights and powers to enforce this
262 subsection as provided by s. 624.307.
263 (d) The commission may adopt rules to implement this
264 subsection.
265 Section 5. Subsection (11) of section 641.315, Florida
266 Statutes, is amended, and subsections (13) and (14) are added to
267 that section, to read:
268 641.315 Provider contracts.—
269 (11) A contract between a health maintenance organization
270 and a dentist licensed under chapter 466 for the provision of
271 services to a subscriber of the health maintenance organization
272 may not contain a provision that requires the dentist to provide
273 services to the subscriber of the health maintenance
274 organization at a fee set by the health maintenance organization
275 unless such services are covered services under the applicable
276 contract. As used in this subsection, the term “covered
277 services” means dental care services for which a reimbursement
278 is available under the subscriber’s contract, notwithstanding or
279 for which a reimbursement would be available but for the
280 application of contractual limitations such as deductibles,
281 coinsurance, waiting periods, annual or lifetime maximums,
282 frequency limitations, alternative benefit payments, or any
283 other limitation.
284 (13)(a) A contract between a health maintenance
285 organization and a dentist licensed under chapter 466 for the
286 provision of services to a subscriber of the health maintenance
287 organization may not specify credit card payment as the only
288 acceptable method for payments from the health maintenance
289 organization to the dentist.
290 (b) At least 10 days before a health maintenance
291 organization pays a claim to a dentist through electronic funds
292 transfer, including, but not limited to, virtual credit card
293 payments, the health maintenance organization shall notify the
294 dentist in writing of all of the following:
295 1. The fees, if any, that are associated with the
296 electronic funds transfer.
297 2. The available methods of payment of claims by the health
298 maintenance organization, with clear instructions to the dentist
299 on how to select an alternative payment method.
300 (c) A health maintenance organization that pays a claim to
301 a dentist through Automated Clearing House (ACH) transfer may
302 not charge a fee solely to transmit the payment to the dentist
303 unless the dentist has consented to the fee. A health
304 maintenance organization may charge reasonable fees for other
305 value-added services related to the ACH transfer, including, but
306 not limited to, transaction management, data management, and
307 portal services.
308 (d) This subsection may not be waived, voided, or nullified
309 by contract, and any contractual clause in conflict with this
310 subsection or which purports to waive any requirements of this
311 subsection is null and void.
312 (e) The office has all rights and powers to enforce this
313 subsection as provided by s. 624.307.
314 (f) The commission may adopt rules to implement this
315 subsection.
316 (14)(a) A health maintenance organization may not deny any
317 claim subsequently submitted by a dentist licensed under chapter
318 466 for procedures specifically included in a prior
319 authorization unless at least one of the following circumstances
320 applies for each procedure denied:
321 1. Benefit limitations, such as annual maximums and
322 frequency limitations not applicable at the time of the prior
323 authorization, are reached subsequent to issuance of the prior
324 authorization.
325 2. The documentation provided by the person submitting the
326 claim fails to support the claim as originally authorized.
327 3. Subsequent to the issuance of the prior authorization,
328 new procedures are provided to the patient or a change in the
329 condition of the patient occurs such that the prior authorized
330 procedure would no longer be considered medically necessary,
331 based on the prevailing standard of care.
332 4. Subsequent to the issuance of the prior authorization,
333 new procedures are provided to the patient or a change in the
334 patient’s condition occurs such that the prior authorized
335 procedure would at that time have required disapproval pursuant
336 to the terms and conditions for coverage under the patient’s
337 plan in effect at the time the prior authorization was issued.
338 5. The denial of the claim was due to one of the following:
339 a. Another payor is responsible for payment.
340 b. The dentist has already been paid for the procedures
341 identified in the claim.
342 c. The claim was submitted fraudulently, or the prior
343 authorization was based in whole or material part on erroneous
344 information provided to the health maintenance organization by
345 the dentist, patient, or other person not related to the
346 organization.
347 d. The person receiving the procedure was not eligible to
348 receive the procedure on the date of service and the health
349 maintenance organization did not know, and with the exercise of
350 reasonable care could not have known, of his or her
351 ineligibility.
352 (b) The subsection may not be waived, voided, or nullified
353 by contract, and any contractual clause in conflict with this
354 subsection or which purports to waive any requirements of this
355 subsection is null and void.
356 (c) The office has all rights and powers to enforce this
357 subsection as provided by s. 624.307.
358 (d) The commission may adopt rules to implement this
359 subsection.
360 Section 6. This act shall take effect July 1, 2024.