Florida Senate - 2025 SB 1526 By Senator Harrell 31-01447-25 20251526__ 1 A bill to be entitled 2 An act relating to health insurance claims; amending 3 s. 627.6131, F.S.; prohibiting a contract between a 4 health insurer and a physician from containing certain 5 restrictions on payment methods; requiring a health 6 insurer to make certain notifications and obtain a 7 physician’s consent before paying a claim to the 8 physician through electronic funds transfer; providing 9 that the physician’s consent applies to the 10 physician’s entire practice; requiring the physician’s 11 consent to bear the signature of the physician; 12 prohibiting the physician from requiring consent on a 13 patient-by-patient basis; prohibiting a health insurer 14 from charging a fee to transmit a payment to a 15 physician through Automated Clearing House (ACH) 16 transfer unless the physician has consented to such 17 fee; revising applicability; providing applicability; 18 prohibiting a health insurer from denying a certain 19 claims submitted by a physician; amending s. 641.315, 20 F.S.; prohibiting a contract between a health 21 maintenance organization and a physician from 22 containing certain restrictions on payment methods; 23 requiring the health maintenance organization to make 24 certain notifications and obtain a physician’s consent 25 before paying a claim to the physician through 26 electronic funds transfer; providing that the 27 physician’s consent applies to the physician’s entire 28 practice; requiring the physician’s consent to bear 29 the signature of the physician; prohibiting the 30 physician from requiring consent on a patient-by 31 patient basis; prohibiting a health maintenance 32 organization from charging a fee to transmit a payment 33 to a physician through ACH transfer unless the 34 physician has consented to such fee; revising 35 applicability; providing applicability; prohibiting a 36 health maintenance organization from denying certain 37 claims submitted by a physician; providing an 38 effective date. 39 40 Be It Enacted by the Legislature of the State of Florida: 41 42 Section 1. Paragraphs (a) through (d) of subsection (20) 43 and paragraphs (a) and (b) of subsection (21) of section 44 627.6131, Florida Statutes, are amended to read: 45 627.6131 Payment of claims.— 46 (20)(a) A contract between a health insurer and a dentist 47 licensed under chapter 466 or a physician licensed under chapter 48 458 or chapter 459 for the provision of services to an insured 49 may not specify credit card payment as the only acceptable 50 method for payments from the health insurer to the dentist or 51 physician. 52 (b) When a health insurer employs the method of claims 53 payment to a dentist or physician through electronic funds 54 transfer, including, but not limited to, virtual credit card 55 payment, the health insurer shall notify the dentist or 56 physician as provided in this paragraph and obtain the dentist’s 57 or physician’s consent before employing the electronic funds 58 transfer. The dentist’s or physician’s consent described in this 59 paragraph applies to the dentist’s or physician’s entire 60 practice. For the purpose of this paragraph, the dentist’s or 61 physician’s consent, which may be given through e-mail, must 62 bear the signature of the dentist or physician. Such signature 63 includes an electronic or digital signature if the form of 64 signature is recognized as a valid signature under applicable 65 federal law or state contract law or an act that demonstrates 66 express consent, including, but not limited to, checking a box 67 indicating consent. The insurer, physician, or dentist may not 68 require that a dentist’s or physician’s consent as described in 69 this paragraph be made on a patient-by-patient basis. The 70 notification provided by the health insurer to the dentist or 71 physician must include all of the following: 72 1. The fees, if any, associated with the electronic funds 73 transfer. 74 2. The available methods of payment of claims by the health 75 insurer, with clear instructions to the dentist or physician on 76 how to select an alternative payment method. 77 (c) A health insurer that pays a claim to a dentist or 78 physician through automated clearinghouse transfer may not 79 charge a fee solely to transmit the payment to the dentist or 80 physician unless the dentist has consented to the fee. 81 (d) For contracts entered into between an insurer and a 82 dentist, this subsection applies to contracts delivered, issued, 83 or renewed on or after January 1, 2025. For contracts entered 84 into between an insurer and a physician, this subsection applies 85 to contracts delivered, issued, or renewed on or after January 86 1, 2026. 87 (21)(a) A health insurer may not deny any claim 88 subsequently submitted by a dentist licensed under chapter 466 89 or a physician licensed under chapter 458 or chapter 459 for 90 procedures specifically included in a prior authorization unless 91 at least one of the following circumstances applies for each 92 procedure denied: 93 1. Benefit limitations, such as annual maximums and 94 frequency limitations not applicable at the time of the prior 95 authorization, are reached subsequent to issuance of the prior 96 authorization. 97 2. The documentation provided by the person submitting the 98 claim fails to support the claim as originally authorized. 99 3. Subsequent to the issuance of the prior authorization, 100 new procedures are provided to the patient or a change in the 101 condition of the patient occurs such that the prior authorized 102 procedure would no longer be considered medically necessary, 103 based on the prevailing standard of care. 104 4. Subsequent to the issuance of the prior authorization, 105 new procedures are provided to the patient or a change in the 106 patient’s condition occurs such that the prior authorized 107 procedure would at that time have required disapproval pursuant 108 to the terms and conditions for coverage under the patient’s 109 plan in effect at the time the prior authorization was issued. 110 5. The denial of the claim was due to one of the following: 111 a. Another payor is responsible for payment. 112 b. The dentist or physician has already been paid for the 113 procedures identified in the claim. 114 c. The claim was submitted fraudulently, or the prior 115 authorization was based in whole or material part on erroneous 116 information provided to the health insurer by the dentist, 117 physician, patient, or other person not related to the insurer. 118 d. The person receiving the procedure was not eligible to 119 receive the procedure on the date of service. 120 e. The services were provided during the grace period 121 established under s. 627.608 or applicable federal regulations, 122 and thedentalinsurer notified the provider that the patient 123 was in the grace period when the dentist or physicianprovider124 requested eligibility or enrollment verification from thedental125 insurer, if such request was made. 126 (b) For contracts entered into between an insurer and a 127 dentist, this subsection applies to all contracts delivered, 128 issued, or renewed on or after January 1, 2025. For contracts 129 entered into between an insurer and a physician, this subsection 130 applies to contracts delivered, issued, or renewed on or after 131 January 1, 2026. 132 Section 2. Paragraphs (a) through (d) of subsection (13) 133 and paragraphs (a) and (b) of subsection (14) of section 134 641.315, Florida Statutes, are amended to read: 135 641.315 Provider contracts.— 136 (13)(a) A contract between a health maintenance 137 organization and a dentist licensed under chapter 466 or a 138 physician licensed under chapter 458 or chapter 459 for the 139 provision of services to a subscriber of the health maintenance 140 organization may not specify credit card payment as the only 141 acceptable method for payments from the health maintenance 142 organization to the dentist or physician. 143 (b) When a health maintenance organization employs the 144 method of claims payment to a dentist or physician through 145 electronic funds transfer, including, but not limited to, 146 virtual credit card payment, the health maintenance organization 147 shall notify the dentist or physician as provided in this 148 paragraph and obtain the dentist’s or physician’s consent before 149 employing the electronic funds transfer. The dentist’s or 150 physician’s consent described in this paragraph applies to the 151 dentist’s or physician’s entire practice. For the purpose of 152 this paragraph, the dentist’s or physician’s consent, which may 153 be given through e-mail, must bear the signature of the dentist 154 or physician. Such signature includes an electronic or digital 155 signature if the form of signature is recognized as a valid 156 signature under applicable federal law or state contract law or 157 an act that demonstrates express consent, including, but not 158 limited to, checking a box indicating consent. The health 159 maintenance organization or dentist or physician may not require 160 that a dentist’s or physician’s consent as described in this 161 paragraph be made on a patient-by-patient basis. The 162 notification provided by the health maintenance organization to 163 the dentist or physician must include all of the following: 164 1. The fees, if any, that are associated with the 165 electronic funds transfer. 166 2. The available methods of payment of claims by the health 167 maintenance organization, with clear instructions to the dentist 168 on how to select an alternative payment method. 169 (c) A health maintenance organization that pays a claim to 170 a dentist or physician through Automated Clearing House transfer 171 may not charge a fee solely to transmit the payment to the 172 dentist or physician unless the dentist or physician has 173 consented to the fee. 174 (d) For contracts entered into between an insurer and a 175 dentist, this subsection applies to contracts delivered, issued, 176 or renewed on or after January 1, 2025. For contracts entered 177 into between an insurer and a physician, this subsection applies 178 to contracts delivered, issued, or renewed on or after January 179 1, 2026. 180 (14)(a) A health maintenance organization may not deny any 181 claim subsequently submitted by a dentist licensed under chapter 182 466 or a physician licensed under chapter 458 or chapter 459 for 183 procedures specifically included in a prior authorization unless 184 at least one of the following circumstances applies for each 185 procedure denied: 186 1. Benefit limitations, such as annual maximums and 187 frequency limitations not applicable at the time of the prior 188 authorization, are reached subsequent to issuance of the prior 189 authorization. 190 2. The documentation provided by the person submitting the 191 claim fails to support the claim as originally authorized. 192 3. Subsequent to the issuance of the prior authorization, 193 new procedures are provided to the patient or a change in the 194 condition of the patient occurs such that the prior authorized 195 procedure would no longer be considered medically necessary, 196 based on the prevailing standard of care. 197 4. Subsequent to the issuance of the prior authorization, 198 new procedures are provided to the patient or a change in the 199 patient’s condition occurs such that the prior authorized 200 procedure would at that time have required disapproval pursuant 201 to the terms and conditions for coverage under the patient’s 202 plan in effect at the time the prior authorization was issued. 203 5. The denial of the claim was due to one of the following: 204 a. Another payor is responsible for payment. 205 b. The dentist or physician has already been paid for the 206 procedures identified in the claim. 207 c. The claim was submitted fraudulently, or the prior 208 authorization was based in whole or material part on erroneous 209 information provided to the health maintenance organization by 210 the dentist, physician, patient, or other person not related to 211 the organization. 212 d. The person receiving the procedure was not eligible to 213 receive the procedure on the date of service. 214 e. The services were provided during the grace period 215 established under s. 627.608 or applicable federal regulations, 216 and thedentalinsurer notified the dentist or physician 217providerthat the patient was in the grace period when the 218 provider requested eligibility or enrollment verification from 219 thedentalinsurer, if such request was made. 220 (b) For contracts entered into between an insurer and a 221 dentist, this subsection applies to all contracts delivered, 222 issued, or renewed on or after January 1, 2025. For contracts 223 entered into between an insurer and a physician, this subsection 224 applies to contracts delivered, issued, or renewed on or after 225 January 1, 2026. 226 Section 3. This act shall take effect July 1, 2025.