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 the dental insurer notified the provider that the patient
123 was in the grace period when the dentist or physician provider
124 requested eligibility or enrollment verification from the dental
125 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 the dental insurer notified the dentist or physician
217 provider that the patient was in the grace period when the
218 provider requested eligibility or enrollment verification from
219 the dental insurer, 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.