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.