Florida Senate - 2026 SB 1198
By Senator Massullo
11-00318A-26 20261198__
1 A bill to be entitled
2 An act relating to health insurance claims; amending
3 s. 408.7057, F.S.; defining the term “denied prior
4 authorization request”; expanding the scope of the
5 statewide provider and health plan claim dispute
6 resolution program to include resolution of denied
7 prior authorization requests; providing that
8 participation in the program is mandatory and
9 prohibiting providers and health plans from opting out
10 of the claim dispute resolution process; revising
11 circumstances under which a claim dispute is exempt
12 from the program’s claim dispute resolution process;
13 providing that respondents in claim disputes may not
14 avoid imposition of a default by declining to
15 participate in the claim dispute resolution process;
16 providing for reimbursement of reasonable costs to
17 providers if the health plan is determined to be the
18 nonprevailing party in a claim dispute involving a
19 denied prior authorization request; requiring the
20 Agency for Health Care Administration to adopt certain
21 rules; amending ss. 627.6131 and 641.315, F.S.;
22 prohibiting contracts between certain physicians and
23 health insurers and health maintenance organizations,
24 respectively, from specifying credit card payments to
25 physicians as the only acceptable method for payments;
26 authorizing use of electronic funds transfers by
27 health insurers and health maintenance organizations,
28 respectively, for payments to physicians under certain
29 circumstances; providing notification requirements;
30 prohibiting health insurers and health maintenance
31 organizations, respectively, from charging fees for
32 automated clearinghouse transfers as claims payments
33 to physicians; providing an exception; providing
34 applicability; prohibiting health insurers and health
35 maintenance organizations, respectively, from denying
36 claims subsequently submitted by physicians for
37 procedures that were included in prior authorizations;
38 providing exceptions; providing applicability;
39 amending ss. 409.967 and 627.64194, F.S.; conforming
40 provisions to changes made by the act; providing an
41 effective date.
42
43 Be It Enacted by the Legislature of the State of Florida:
44
45 Section 1. Section 408.7057, Florida Statutes, is amended
46 to read:
47 408.7057 Mandatory statewide provider and health plan claim
48 dispute resolution program.—
49 (1) As used in this section, the term:
50 (a) “Agency” means the Agency for Health Care
51 Administration.
52 (b) “Denied prior authorization request” means, with
53 respect to a request submitted by a provider for prior
54 authorization of a health care service, supply, or medication, a
55 health plan has made a determination that the request is wholly
56 or partially disapproved, has not been acted upon within the
57 time limits established by law or contract, or is approved
58 subject to materially restrictive conditions that prevent the
59 service, supply, or medication from being furnished as
60 clinically indicated.
61 (c) “Health plan” means a health maintenance organization
62 or a prepaid health clinic certified under chapter 641, a
63 prepaid health plan authorized under s. 409.912, an exclusive
64 provider organization certified under s. 627.6472, or a major
65 medical expense health insurance policy, as defined in s.
66 627.643(2)(e), offered by a group or an individual health
67 insurer licensed pursuant to chapter 624, including a preferred
68 provider organization under s. 627.6471.
69 (d)(c) “Resolution organization” means a qualified
70 independent third-party claim-dispute-resolution entity selected
71 by and contracted with the Agency for Health Care
72 Administration.
73 (2)(a) The agency shall establish a program to provide
74 assistance to contracted and noncontracted providers and health
75 plans for resolution of claim disputes and denied prior
76 authorization requests that are not resolved by the provider and
77 the health plan. The agency shall contract with a resolution
78 organization to timely review and consider claim disputes and
79 denied prior authorization requests submitted by providers and
80 health plans and recommend to the agency an appropriate
81 resolution of those disputes. The agency shall establish by rule
82 jurisdictional amounts and methods of aggregation for claim
83 disputes and denied prior authorization requests that may be
84 considered by the resolution organization.
85 (b) Participation in the claim dispute resolution program
86 is mandatory, and a provider or health plan may not opt out of
87 the program’s claim dispute resolution process. The resolution
88 organization shall review all claim disputes filed by contracted
89 and noncontracted providers and health plans unless the disputed
90 claim:
91 1. Is related to interest payment;
92 2. Does not meet the jurisdictional amounts or the methods
93 of aggregation established by agency rule, as provided in
94 paragraph (a);
95 3. Is part of an internal grievance in a Medicare managed
96 care organization or a reconsideration appeal through the
97 Medicare appeals process;
98 4. Is related to a health plan that is not regulated by the
99 state;
100 5. Is part of a Medicaid fair hearing pursued under 42
101 C.F.R. ss. 431.220 et seq.;
102 6. Is specifically the subject of an existing lawsuit filed
103 basis for an action pending in state or federal court before the
104 submission of the claim to the resolution organization; or
105 7. Is subject to a binding claim-dispute-resolution process
106 provided by contract entered into before prior to October 1,
107 2000, between the provider and the managed care organization.
108 (c) Contracts entered into or renewed on or after October
109 1, 2000, may require exhaustion of an internal dispute
110 resolution process as a prerequisite to the submission of a
111 claim by a provider or a health plan to the resolution
112 organization.
113 (d) A contracted or noncontracted provider or health plan
114 may not file a claim dispute with the resolution organization
115 more than 12 months after a final determination has been made on
116 a claim by a health plan or provider.
117 (e) The resolution organization shall require the health
118 plan or provider submitting the claim dispute to submit any
119 supporting documentation to the resolution organization within
120 15 days after receipt by the health plan or provider of a
121 request from the resolution organization for documentation in
122 support of the claim dispute. The resolution organization may
123 extend the time if appropriate. Failure to submit the supporting
124 documentation within such time period shall result in the
125 dismissal of the submitted claim dispute.
126 (f) The resolution organization shall require the
127 respondent in the claim dispute to submit all documentation in
128 support of its position within 15 days after receiving a request
129 from the resolution organization for supporting documentation.
130 The resolution organization may extend the time if appropriate.
131 Failure to submit the supporting documentation within such time
132 period shall result in a default against the health plan or
133 provider. A respondent may not avoid a default by declining to
134 participate in the claim dispute resolution process set forth in
135 this section. In the event of such a default, the resolution
136 organization shall issue its written recommendation to the
137 agency that a default be entered against the defaulting entity.
138 The written recommendation shall include a recommendation to the
139 agency that the defaulting entity shall pay the entity
140 submitting the claim dispute the full amount of the claim
141 dispute, plus all accrued interest, and shall be considered a
142 nonprevailing party for the purposes of this section.
143 (g)1. If on an ongoing basis during the preceding 12
144 months, the agency has reason to believe that a pattern of
145 noncompliance with s. 627.6131 and s. 641.3155 exists on the
146 part of a particular health plan or provider, the agency shall
147 evaluate the information contained in these cases to determine
148 whether the information evidences a pattern and report its
149 findings, together with substantiating evidence, to the
150 appropriate licensure or certification entity for the health
151 plan or provider.
152 2. In addition, the agency shall prepare a report to the
153 Governor and the Legislature by February 1 of each year,
154 enumerating: claims dismissed; defaults issued; and failures to
155 comply with agency final orders issued under this section.
156 (h) Either the contracted or noncontracted provider or the
157 health plan may make an offer to settle the claim dispute when
158 it submits a request for a claim dispute and supporting
159 documentation. The offer to settle the claim dispute must state
160 its total amount, and the party to whom it is directed has 15
161 days to accept the offer once it is received. If the party
162 receiving the offer does not accept the offer and the final
163 order amount is more than 90 percent or less than 110 percent of
164 the offer amount, the party receiving the offer must pay the
165 final order amount to the offering party and is deemed a
166 nonprevailing party for purposes of this section. The amount of
167 an offer made by a contracted or noncontracted provider to
168 settle an alleged underpayment by the health plan must be
169 greater than 110 percent of the reimbursement amount the
170 provider received. The amount of an offer made by a health plan
171 to settle an alleged overpayment to the provider must be less
172 than 90 percent of the alleged overpayment amount by the health
173 plan. Both parties may agree to settle the disputed claim at any
174 time, for any amount, regardless of whether an offer to settle
175 was made or rejected.
176 (3) The agency shall adopt rules to establish a process to
177 be used by the resolution organization in considering claim
178 disputes submitted by a provider or health plan which must
179 include:
180 (a) That the resolution organization review and consider
181 all documentation submitted by both the health plan and the
182 provider;
183 (b) That the resolution organization’s recommendation make
184 findings of fact;
185 (c) That either party may request that the resolution
186 organization conduct an evidentiary hearing in which both sides
187 can present evidence and examine witnesses, and for which the
188 cost of the hearing is equally shared by the parties;
189 (d) That the resolution organization may not communicate ex
190 parte with either the health plan or the provider during the
191 dispute resolution;
192 (e) That the resolution organization’s written
193 recommendation, including findings of fact relating to the
194 calculation under s. 641.513(5) for the recommended amount due
195 for the disputed claim, include any evidence relied upon; and
196 (f) That the resolution organization issue a written
197 recommendation to the agency within 60 days after the requested
198 information is received by the resolution organization within
199 the timeframes specified by the resolution organization. In no
200 event shall the review time exceed 90 days following receipt of
201 the initial claim dispute submission by the resolution
202 organization.
203 (4) Within 30 days after receipt of the recommendation of
204 the resolution organization, the agency shall adopt the
205 recommendation as a final order. The final order is subject to
206 judicial review pursuant to s. 120.68.
207 (5) The agency shall notify within 7 days the appropriate
208 licensure or certification entity whenever there is a violation
209 of a final order issued by the agency pursuant to this section.
210 (6) The entity that does not prevail in the agency’s order
211 must pay a review cost to the review organization, as determined
212 by agency rule. Such rule must provide for an apportionment of
213 the review fee in any case in which both parties prevail in
214 part. If the nonprevailing party fails to pay the ordered review
215 cost within 35 days after the agency’s order, the nonpaying
216 party is subject to a penalty of not more than $500 per day
217 until the penalty is paid.
218 (7) If a claim dispute under this section involves a denied
219 prior authorization request and the health plan is determined to
220 be the nonprevailing party, the health plan must reimburse the
221 provider for the provider’s reasonable costs incurred in
222 bringing the claim, including any filing fees and administrative
223 costs assessed by the agency or its designee. The agency shall
224 adopt rules to specify allowable costs and procedures for
225 recovering such costs under this subsection.
226 (8) The agency may adopt rules to administer this section.
227 Section 2. Subsections (20) and (21) of section 627.6131,
228 Florida Statutes, are amended to read:
229 627.6131 Payment of claims.—
230 (20)(a) A contract between a health insurer and a dentist
231 licensed under chapter 466 or a physician licensed under chapter
232 458 or chapter 459 for the provision of services to an insured
233 may not specify credit card payment as the only acceptable
234 method for payments from the health insurer to the dentist or
235 physician.
236 (b) When a health insurer employs the method of claims
237 payment to a dentist or physician through electronic funds
238 transfer, including, but not limited to, virtual credit card
239 payment, the health insurer shall notify the dentist or
240 physician as provided in this paragraph and obtain the dentist’s
241 or physician’s consent before employing the electronic funds
242 transfer. The dentist’s or physician’s consent described in this
243 paragraph applies to the dentist’s or physician’s entire
244 practice. For the purpose of this paragraph, the dentist’s or
245 physician’s consent, which may be given through e-mail, must
246 bear the signature of the dentist or physician. Such signature
247 includes an electronic or digital signature if the form of
248 signature is recognized as a valid signature under applicable
249 federal law or state contract law or an act that demonstrates
250 express consent, including, but not limited to, checking a box
251 indicating consent. The health insurer or the dentist or
252 physician may not require that a dentist’s or physician’s
253 consent as described in this paragraph be made on a patient-by
254 patient basis. The notification provided by the health insurer
255 to the dentist or physician must include all of the following:
256 1. The fees, if any, associated with the electronic funds
257 transfer.
258 2. The available methods of payment of claims by the health
259 insurer, with clear instructions to the dentist or physician on
260 how to select an alternative payment method.
261 (c) A health insurer that pays a claim to a dentist or
262 physician through automated clearinghouse transfer may not
263 charge a fee solely to transmit the payment to the dentist or
264 physician unless the dentist or physician has consented to the
265 fee.
266 (d) This subsection applies to all contracts:
267 1. Between a health insurer and a dentist which are
268 delivered, issued, or renewed on or after January 1, 2025.
269 2. Between a health insurer and a physician which are
270 delivered, issued, or renewed on or after January 1, 2027.
271 (e) The office has all rights and powers to enforce this
272 subsection as provided by s. 624.307.
273 (f) The commission may adopt rules to implement this
274 subsection.
275 (21)(a) A health insurer may not deny any claim
276 subsequently submitted by a dentist licensed under chapter 466
277 or a physician licensed under chapter 458 or chapter 459 for
278 procedures specifically included in a prior authorization unless
279 at least one of the following circumstances applies for each
280 procedure denied:
281 1. Benefit limitations, such as annual maximums and
282 frequency limitations not applicable at the time of the prior
283 authorization, are reached subsequent to issuance of the prior
284 authorization.
285 2. The documentation provided by the person submitting the
286 claim fails to support the claim as originally authorized.
287 3. Subsequent to the issuance of the prior authorization,
288 new procedures are provided to the patient or a change in the
289 condition of the patient occurs such that the prior authorized
290 procedure would no longer be considered medically necessary,
291 based on the prevailing standard of care.
292 4. Subsequent to the issuance of the prior authorization,
293 new procedures are provided to the patient or a change in the
294 patient’s condition occurs such that the prior authorized
295 procedure would at that time have required disapproval pursuant
296 to the terms and conditions for coverage under the patient’s
297 plan in effect at the time the prior authorization was issued.
298 5. The denial of the claim was due to one of the following:
299 a. Another payor is responsible for payment.
300 b. The dentist or physician has already been paid for the
301 procedures identified in the claim.
302 c. The claim was submitted fraudulently, or the prior
303 authorization was based in whole or material part on erroneous
304 information provided to the health insurer by the dentist or
305 physician, patient, or other person not related to the insurer.
306 d. The person receiving the procedure was not eligible to
307 receive the procedure on the date of service.
308 e. The services were provided during the grace period
309 established under s. 627.608 or applicable federal regulations,
310 and the dental insurer notified the dentist or physician
311 provider that the patient was in the grace period when the
312 dentist or physician provider requested eligibility or
313 enrollment verification from the dental insurer, if such request
314 was made.
315 (b) This subsection applies to all contracts:
316 1. Between a health insurer and a dentist which are
317 delivered, issued, or renewed on or after January 1, 2025.
318 2. Between a health insurer and a physician which are
319 delivered, issued, or renewed on or after January 1, 2027.
320 (c) The office has all rights and powers to enforce this
321 subsection as provided by s. 624.307.
322 (d) The commission may adopt rules to implement this
323 subsection.
324 Section 3. Subsections (13) and (14) of section 641.315,
325 Florida Statutes, are amended to read:
326 641.315 Provider contracts.—
327 (13)(a) A contract between a health maintenance
328 organization and a dentist licensed under chapter 466 or a
329 physician licensed under chapter 458 or chapter 459 for the
330 provision of services to a subscriber of the health maintenance
331 organization may not specify credit card payment as the only
332 acceptable method for payments from the health maintenance
333 organization to the dentist or physician.
334 (b) When a health maintenance organization employs the
335 method of claims payment to a dentist or physician through
336 electronic funds transfer, including, but not limited to,
337 virtual credit card payment, the health maintenance organization
338 shall notify the dentist or physician as provided in this
339 paragraph and obtain the dentist’s or physician’s consent before
340 employing the electronic funds transfer. The dentist’s or
341 physician’s consent described in this paragraph applies to the
342 dentist’s or physician’s entire practice. For the purpose of
343 this paragraph, the dentist’s or physician’s consent, which may
344 be given through e-mail, must bear the signature of the dentist
345 or physician. Such signature includes an electronic or digital
346 signature if the form of signature is recognized as a valid
347 signature under applicable federal law or state contract law or
348 an act that demonstrates express consent, including, but not
349 limited to, checking a box indicating consent. The health
350 maintenance organization or the dentist or physician may not
351 require that a dentist’s or physician’s consent as described in
352 this paragraph be made on a patient-by-patient basis. The
353 notification provided by the health maintenance organization to
354 the dentist or physician must include all of the following:
355 1. The fees, if any, that are associated with the
356 electronic funds transfer.
357 2. The available methods of payment of claims by the health
358 maintenance organization, with clear instructions to the dentist
359 or physician on how to select an alternative payment method.
360 (c) A health maintenance organization that pays a claim to
361 a dentist or physician through automated clearing house transfer
362 may not charge a fee solely to transmit the payment to the
363 dentist or physician unless the dentist or physician has
364 consented to the fee.
365 (d) This subsection applies to all contracts:
366 1. Between a health maintenance organization and a dentist
367 which are delivered, issued, or renewed on or after January 1,
368 2025.
369 2. Between a health maintenance organization and a
370 physician which are delivered, issued, or renewed on or after
371 January 1, 2027.
372 (e) The office has all rights and powers to enforce this
373 subsection as provided by s. 624.307.
374 (f) The commission may adopt rules to implement this
375 subsection.
376 (14)(a) A health maintenance organization may not deny any
377 claim subsequently submitted by a dentist licensed under chapter
378 466 or a physician licensed under chapter 458 or chapter 459 for
379 procedures specifically included in a prior authorization unless
380 at least one of the following circumstances applies for each
381 procedure denied:
382 1. Benefit limitations, such as annual maximums and
383 frequency limitations not applicable at the time of the prior
384 authorization, are reached subsequent to issuance of the prior
385 authorization.
386 2. The documentation provided by the person submitting the
387 claim fails to support the claim as originally authorized.
388 3. Subsequent to the issuance of the prior authorization,
389 new procedures are provided to the patient or a change in the
390 condition of the patient occurs such that the prior authorized
391 procedure would no longer be considered medically necessary,
392 based on the prevailing standard of care.
393 4. Subsequent to the issuance of the prior authorization,
394 new procedures are provided to the patient or a change in the
395 patient’s condition occurs such that the prior authorized
396 procedure would at that time have required disapproval pursuant
397 to the terms and conditions for coverage under the patient’s
398 plan in effect at the time the prior authorization was issued.
399 5. The denial of the claim was due to one of the following:
400 a. Another payor is responsible for payment.
401 b. The dentist or physician has already been paid for the
402 procedures identified in the claim.
403 c. The claim was submitted fraudulently, or the prior
404 authorization was based in whole or material part on erroneous
405 information provided to the health maintenance organization by
406 the dentist or physician, patient, or other person not related
407 to the organization.
408 d. The person receiving the procedure was not eligible to
409 receive the procedure on the date of service.
410 e. The services were provided during the grace period
411 established under s. 627.608 or applicable federal regulations,
412 and the dental insurer notified the dentist or physician
413 provider that the patient was in the grace period when the
414 dentist or physician provider requested eligibility or
415 enrollment verification from the dental insurer, if such request
416 was made.
417 (b) This subsection applies to all contracts:
418 1. Between a health maintenance organization and a dentist
419 which are delivered, issued, or renewed on or after January 1,
420 2025.
421 2. Between a health maintenance organization and a
422 physician which are delivered, issued, or renewed on or after
423 January 1, 2027.
424 (c) The office has all rights and powers to enforce this
425 subsection as provided by s. 624.307.
426 (d) The commission may adopt rules to implement this
427 subsection.
428 Section 4. Paragraph (n) of subsection (2) of section
429 409.967, Florida Statutes, is amended to read:
430 409.967 Managed care plan accountability.—
431 (2) The agency shall establish such contract requirements
432 as are necessary for the operation of the statewide managed care
433 program. In addition to any other provisions the agency may deem
434 necessary, the contract must require:
435 (n) Provider dispute resolution.—Disputes between a plan
436 and a provider must may be resolved as described in s. 408.7057.
437 Section 5. Subsection (6) of section 627.64194, Florida
438 Statutes, is amended to read:
439 627.64194 Coverage requirements for services provided by
440 nonparticipating providers; payment collection limitations.—
441 (6) Any dispute with regard to the reimbursement to the
442 nonparticipating provider of emergency or nonemergency services
443 as provided in subsection (4) shall be resolved in a court of
444 competent jurisdiction or through the mandatory voluntary
445 dispute resolution process in s. 408.7057.
446 Section 6. This act shall take effect July 1, 2026.