HB 1015 full text · Session Watch

1 A bill to be entitled

2 An act relating to insurance claims payments to health

3 care providers; creating s. 627.4193, F.S.; providing

4 definitions; prohibiting payment adjudicators from

5 downcoding health care services under certain

6 circumstances; providing exceptions; providing

7 requirements for such exceptions; requiring health

8 insurers to ensure that their downcoding policies are

9 updated and to ensure compliance with specified

10 provisions on downcoding; authorizing investigations

11 and actions against noncompliance; providing certain

12 presumption in favor of physicians' determination

13 regarding patients' diagnoses and service orders;

14 providing calculations of interests on health

15 insurers' nonpayment and underpayment due to

16 downcoding; providing causes of action for health care

17 providers; amending s. 627.42392, F.S.; providing and

18 revising definitions; requiring utilization review

19 entities to establish electronic prior authorizations

20 to accept prior authorization requests; providing

21 requirements for such entities and for prior

22 authorization processes; prohibiting such entities

23 from implementing new requirements, restrictions, and

24 changes; providing exceptions; providing reporting

25 requirements; requiring the Office of Insurance

26 Regulation to publish a report based on such entities'

27 reports; providing requirements for adverse

28 determinations made by such entities on health care

29 providers' claims; providing a timeframe for such

30 entities' determination on claims; prohibiting prior

31 authorization requirements under certain

32 circumstances; prohibiting prior authorization

33 revocations, limits, conditions, and restrictions

34 under certain circumstances; providing exceptions;

35 providing validity timeframe of prior authorizations

36 under certain circumstances; providing construction;

37 amending ss. 627.6131 and 641.3155, F.S.; providing

38 and revising definitions; revising requirements and

39 timeframes for responses from health insurers and

40 health maintenance organizations, respectively, to

41 submitted claims; revising interests on overdue

42 payments of claims; authorizing health care providers

43 to refuse to participate in internal dispute

44 resolution processes under certain circumstances;

45 prohibiting health insurers and health maintenance

46 organizations, respectively, from retrospectively,

47 rather than retroactively, denying claims because of

48 insured and enrollee ineligibility beyond a specified

49 timeframe; revising such timeframe; revising

50 applicability; providing construction; prohibiting

51 health insurers and health maintenance organizations,

52 respectively, from requesting or requiring certain

53 information from health care providers under certain

54 circumstances; providing causes of action for health

55 care providers under certain circumstances; amending

56 s. 395.1065, F.S.; conforming cross-references;

57 providing an effective date.

59 Be It Enacted by the Legislature of the State of Florida:

61 Section 1. Section 627.4193, Florida Statutes, is created

62 to read:

63 627.4193 Restrictions on health insurance reimbursement

64 downcoding.—

65 (1) As used in this section, the term:

66 (a) "Downcode" or "downcoding" means the alteration by a

67 payment adjudicator of a service code to another service code or

68 the alteration, addition, or removal by a payment adjudicator of

69 a modifier, when the changed code or modifier is associated with

70 a lower payment amount than the service code or modifier billed

71 by the provider or facility.

72 (b) "Health insurer" means any entity that offers health

73 insurance coverage, whether through a fully insured plan or

74 self-insured plan or fund, including, as applicable:

75 1. An authorized health insurer offering health insurance

76 as defined in s. 624.603, as well as any entity that offers a

77 commercial self-insurance fund as defined in s. 624.462(2) or

78 group self-insurance fund as described in s. 624.4621.

79 2. A health insurer that is subject to any of the

80 provisions of this chapter, as well as any entity that offers a

81 self-insurance plan or a group self-insurance plan.

82 3. A managed care plan as defined in s. 409.962.

83 4. A health maintenance organization as defined in s.

84 641.19.

85 (c) "Medical record" means the comprehensive collection of

86 documentation, including clinical notes, diagnostic reports, and

87 other relevant information, which supports the health care

88 services provided.

89 (d) "Participation agreement" means a written contract or

90 agreement between a health insurer and a provider which outlines

91 the terms and conditions of participation, reimbursement rates,

92 and other relevant details.

93 (e) "Payment adjudicator" means a health insurer or any

94 entity that provides, offers to provide, or administers payment

95 on behalf of a health insurer, as well any pharmacy benefit

96 manager as defined in s. 624.490(1), and any other individual or

97 entity that provides, offers to provide, or administers payment

98 for hospital services, outpatient services, medical services,

99 prescription drugs, or other health care services, to a person

100 treated by a health care professional or facility in this state

101 under a policy, plan, or contract.

102 (f) "Provider" means any health care professional,

103 facility, or entity that submits claims for reimbursement for

104 covered health care services.

105 (2) Payment adjudicators are prohibited from downcoding a

106 health care service billed by, or on behalf of, a provider, if

107 the health care service was ordered by a provider that is in-

108 network with the applicable health insurer, unless such

109 downcoding is otherwise expressly permitted under the

110 participation agreement between the health insurer and the

111 provider.

112 (3) If downcoding is expressly permitted under the

113 participation agreement, the payment adjudicator must provide

114 the following information to the provider before making its

115 initial payment or notice of denial of payment:

116 (a) A statement indicating that the service code or

117 modifier billed by the provider or facility is going to be

118 downcoded.

119 (b) An explanation detailing the reasons for downcoding

120 the claim. This explanation must include a clear description of

121 the service codes or modifiers that were altered, added, or

122 removed, if applicable.

123 (c) The payment amount that the payment adjudicator would

124 otherwise make if the service code or modifier is not downcoded.

125 (d) A statement that the provider may contest the

126 downcoding of the applicable service code or modifier by filing

127 a contestation with the payment adjudicator with respect to the

128 downcoding within 15 days after receipt of the notice of

129 downcoding.

130 (e) A statement that by contesting the downcoding of the

131 applicable service code or modifier, the provider does not waive

132 any of its legal rights and claims against the health insurer or

133 payment adjudicator to the fullest extent permissible under law.

134 (4) Even if the participation agreement expressly permits

135 downcoding, a payment adjudicator is prohibited from downcoding

136 a service without first conducting a review of the associated

137 medical record to ensure the accuracy of the coding change.

138 (5) A payment adjudicator is prohibited from downcoding

139 for orders by a licensed nurse.

140 (6) Notwithstanding any provision in this section, a

141 payment adjudicator that proceeds to downcode a service code or

142 modifier, regardless of whether such downcoding is contested by

143 the provider, is solely responsible for any violations of law

144 associated with such downcoding.

145 (7) Payment adjudicators are required to maintain clear

146 and accessible downcoding policies on their official website.

147 These policies must include:

148 (a) An overview of the circumstances under which

149 downcoding may occur.

150 (b) The process and criteria used for conducting reviews

151 of downcoded claims, including the role of medical record

152 review.

153 (c) Information about the internal mechanisms for ensuring

154 consistency and accuracy in downcoding practices.

155 (d) Information regarding the processes for contesting

156 with the payment adjudicator the downcoding of a service code,

157 which processes must offer appeal rights for the provider and

158 the patient, and peer review by a licensed physician before the

159 downcoding.

160 (8) Health insurers shall ensure that their downcoding

161 policies are updated as needed to reflect any changes in

162 regulations, industry standards, or internal procedures.

163 (9) Health insurers shall ensure compliance with this

164 section and shall develop internal procedures to implement and

165 adhere to the requirements outlined in this section.

166 (10) Regulatory authorities, including, but not limited

167 to, the Office of Insurance Regulation, may investigate and take

168 appropriate actions in cases of noncompliance with this section.

169 (11) When a particular health care service is ordered by a

170 licensed physician, there shall be a presumption that the

171 physician determination regarding the diagnosis of the patient

172 and service order by the physician is correct and sufficient,

173 absent a coding error which the health insurer must first verify

174 with the physician before downcoding for such error.

175 (12) If an applicable court, arbitration tribunal, or

176 other binding legal process determines that a claim was subject

177 to an inappropriate or impermissible downcoding, whether in

178 breach of contract, statute, common law, or otherwise, such that

179 nonpayment or underpayment of the original claim has occurred,

180 then in accordance with s. 627.6131, interest shall be

181 calculated upon the full total amount that should have been paid

182 on the claim as of the applicable time period for payment

183 specified in s. 627.6131.

184 (13) In the instance of a violation of this section, a

185 provider shall have a private cause of action to proceed against

186 the health insurer or payment adjudicator in the applicable

187 tribunal for the violation.

188 Section 2. Section 627.42392, Florida Statutes, is amended

189 to read:

190 627.42392 Prior authorization.—

191 (1) As used in this section, the term:

192 (a) "Adverse determination" means a decision by a health

193 insurer or utilization review entity that the health care

194 services rendered, or proposed to be rendered, to a patient are

195 denied, reduced, or terminated. The term does not include a

196 decision to deny, reduce, or terminate services that are

197 determined to have been billed in duplicate bills or that are

198 confirmed with the provider to have been billed in error.

199 (b) "Electronic prior authorization process" does not

200 include transmissions through a facsimile machine.

201 (c) "Emergency health care service" means medical

202 screening, examination, and evaluation by a physician, or, to

203 the extent permitted by applicable law, by other appropriate

204 personnel under the supervision of a physician, to determine if

205 an emergency medical condition exists and, if it does, the care,

206 treatment, or surgery by a physician necessary to relieve or

207 eliminate the emergency medical condition, within the service

208 capability of the facility.

209 (d) "Emergency medical condition" means a medical

210 condition manifesting itself by acute symptoms of sufficient

211 severity, including severe pain, such that a prudent layperson

212 who possesses an average knowledge of health and medicine could

213 reasonably expect the absence of immediate medical attention to

214 result in any of the conditions listed in s. 395.002(8).

215 (e) "Health insurer" means any entity that offers health

216 insurance coverage, whether through a fully insured plan or

217 self-insured plan or fund, including, as applicable:

218 1. An authorized health insurer offering health insurance

219 as defined in s. 624.603, as well as any entity that offers a

220 commercial self-insurance fund as defined in s. 624.462(2) or a

221 group self-insurance fund as described in s. 624.4621.

222 2. A health insurer that is subject to any of the

223 provisions of this chapter, as well as any entity that offers a

224 self-insurance plan or a group self-insurance plan.

225 3. A managed care plan as defined in s. 409.962.

226 4. A health maintenance organization as defined in s.

227 641.19.

228 (f) "Prior authorization" means the process by which

229 utilization review entities determine the medical necessity or

230 medical appropriateness of otherwise covered health care

231 services before the rendering of such health care services. The

232 term also includes any requirement by a health insurer or

233 utilization review entity that an enrollee or health care

234 provider notify the health insurer or utilization review entity

235 before the provision of a health care service.

236 (g) "Urgent health care service" means a health care

237 service that, if the timeframe for making a nonexpedited prior

238 authorization is applied, could, in the opinion of a physician

239 with knowledge of the patient's medical condition:

240 1. Seriously jeopardize the life or health of the patient

241 or the ability of the patient to regain maximum function; or

242 2. Subject the patient to severe pain that cannot be

243 adequately managed without the care, treatment, or prescription

244 drugs that are the subject of the prior authorization request.

245 (h) "Utilization review activity" means any activity

246 prospective to, concurrent with, or retrospective to, the

247 provision of a nonemergency health care service, to determine

248 whether payment shall be made in full or shall be subject to an

249 adverse determination. Utilization review activity is

250 prohibited:

251 1. To the extent restricted or prohibited by an agreement

252 with a health care provider;

253 2. For an emergency health care service; or

254 3. For a service provided to a patient who is experiencing

255 an emergency medical condition.

256 (i) "Utilization review entity" means an entity permitted

257 under the applicable agreement with a health care provider or

258 otherwise permitted by a provider that does not have such an

259 agreement to perform utilization review activities or upon whose

260 behalf utilization review activities are performed, including,

261 as applicable:

262 1. An authorized health insurer offering health insurance

263 as defined in s. 624.603, as well as any entity that offers a

264 commercial self-insurance fund as defined in s. 624.462(2) or

265 group self-insurance fund as described in s. 624.4621.

266 2. A health insurer that is subject to any of the

267 provisions of this chapter, as well as any entity that offers a

268 self-insurance plan or a group self-insurance plan.

269 3. A managed care plan as defined in s. 409.962.

270 4. A health maintenance organization as defined in s.

271 641.19.

272 5. A pharmacy benefit manager as defined in s. 624.490(1).

273 6. Any other individual or entity that provides, offers to

274 provide, or administers payment for hospital services,

275 outpatient services, medical services, prescription drugs, or

276 other health care services to a person treated by a health care

277 professional or facility in this state under a policy, plan,

278 contract, or fund ~~"health insurer" means an authorized insurer~~

279 ~~offering health insurance as defined in s. 624.603, a managed~~

280 ~~care plan as defined in s. 409.962(10), or a health maintenance~~

281 ~~organization as defined in s. 641.19(12).~~

282 (2) Notwithstanding any other provision of law, a

283 utilization review entity that ~~effective January 1, 2017, or six~~

284 ~~(6) months after the effective date of the rule adopting the~~

285 ~~prior authorization form, whichever is later, a health insurer,~~

286 ~~or a pharmacy benefits manager on behalf of the health insurer,~~

287 ~~which~~ does not provide an electronic prior authorization process

288 for use by its contracted providers, shall only use the prior

289 authorization form that has been approved by the Financial

290 Services Commission for granting a prior authorization for a

291 medical procedure, course of treatment, or prescription drug

292 benefit. Such form shall be no longer than ~~may not exceed~~ two

293 pages in length, excluding any instructions or guiding

294 documentation, and must include all clinical documentation

295 necessary for the utilization review entity ~~health insurer~~ to

296 make a decision. At a minimum, the form must include: (1)

297 sufficient patient information to identify the member, date of

298 birth, full name, and Health Plan ID number; (2) provider name,

299 address and phone number; (3) the medical procedure, course of

300 treatment, or prescription drug benefit being requested,

301 including the medical reason therefor, and all services tried

302 and failed; (4) any laboratory documentation required; and (5)

303 an attestation that all information provided is true and

304 accurate.

305 (3) The Financial Services Commission in consultation with

306 the Agency for Health Care Administration shall adopt by rule

307 guidelines for all prior authorization forms which ensure the

308 general uniformity of such forms.

309 (4) A utilization review entity must establish and offer a

310 secure, interactive online electronic prior authorization to

311 accept electronic prior authorization requests. The process of

312 electronic prior authorization must allow a person seeking a

313 prior authorization the ability to upload documentation if such

314 documentation is required by the utilization review entity to

315 adjudicate the prior authorization request. Once a provider

316 grants a health insurer access to a patient's electronic medical

317 record, the provider shall be deemed to have supplied all

318 information necessary for prior authorization of the health care

319 service, including, without limitation, all information that is

320 reasonably required by the health insurer, other than for an

321 emergency health care service or for a service provided to a

322 patient who is experiencing an emergency medical condition, in

323 advance of the provision of service, and the health insurer

324 asserts is missing as of the date of such service. Additional

325 information or documentation, regardless of whether the

326 utilization review entity requests any additional information,

327 shall be deemed unnecessary, and deemed not required, for prior

328 authorization of the health care service, and any request for

329 additional information or any position of the utilization review

330 entity or any third party acting on behalf of the utilization

331 review entity regarding any lack of information from the

332 provider is prohibited from being used to deny, pend, or delay

333 prior authorization of the health care service.

334 (5)(4) Electronic prior authorization approvals do not

335 preclude benefit verification or medical review by the health

336 insurer under either the medical or pharmacy benefits.

337 (6) A utilization review entity's prior authorization

338 process is prohibited from requiring information that is not

339 needed to make a determination or facilitate a determination of

340 medical necessity of the requested medical procedure, course of

341 treatment, or prescription drug benefit.

342 (7) A utilization review entity shall disclose all of its

343 prior authorization requirements and restrictions, including any

344 written clinical criteria, in a publicly accessible manner on

345 its website. This information shall be explained in detail and

346 in clear and ordinary terms.

347 (8) A utilization review entity is prohibited from

348 implementing any new requirements or restrictions and from

349 making changes to existing requirements or restrictions on

350 obtaining prior authorization unless:

351 (a) The changes have been available on a publicly

352 accessible website for at least 60 days before they are

353 implemented;

354 (b) Policyholders and health care providers who are

355 affected by the new requirements and restrictions or changes to

356 the requirements and restrictions are provided with a written

357 notice of the changes at least 60 days before they are

358 implemented, with such notice being delivered electronically or

359 by other means as agreed to by the policyholder or the health

360 care provider; and

361 (c) All applicable amendments to a provider's agreement

362 with the applicable health insurer or utilization review entity

363 have been obtained and memorialized in a mutually agreed-upon

364 writing before such implementation.

365 (9)(a) Utilization review entities shall, by March 31 of

366 each year, submit a report to the Office of Insurance Regulation

367 with the following data elements for the prior calendar year:

368 1. A list of all items and services requiring prior

369 authorization.

370 2. The percentage of standard prior authorization requests

371 approved by the utilization review entity and aggregated by item

372 or service.

373 3. The percentage of standard prior authorization requests

374 denied by the utilization review entity aggregated by item or

375 service.

376 4. The percentage of standard prior authorization requests

377 approved by the utilization review entity after appeal by item

378 or service.

379 5. The percentage of prior authorization where the

380 timeframe for review was extended and request approved by item

381 or service.

382 6. The percentage of expedited prior authorization

383 requests approved by the utilization review entity by item or

384 service.

385 7. The percentage of expedited prior authorization

386 requests denied by the utilization review entity by item or

387 service.

388 8. The percentage of expedited prior authorization

389 requests approved by the utilization review entity after appeal

390 by item or service.

391 9. The average and median time between submission of a

392 request for prior authorization and the utilization review

393 entity's decision for standard prior authorizations by item or

394 service.

395 10. The average and median time between submission of a

396 request for prior authorization and the utilization review

397 entity's decision for expedited prior authorizations by item or

398 service.

399 (b) The Office of Insurance Regulation shall, by July 1 of

400 each year, publish a report on its website detailing the

401 information in paragraph (a) submitted by utilization review

402 entities.

403 (10) Utilization review entities must ensure that all

404 adverse determinations are made by a physician licensed under

405 chapter 458 or chapter 459. The physician must:

406 (a) Possess a current and valid nonrestricted license to

407 practice medicine in this state;

408 (b) Be of the same specialty as the physician who

409 typically manages the medical condition or disease, or provides

410 the health care service involved in the request;

411 (c) Have at least 5 years of experience treating patients

412 with the medical condition or disease for which the health care

413 service is being requested; and

414 (d) Not have any direct or indirect financial arrangement

415 with the utilization review entity that rewards or incentivizes,

416 financially or otherwise, such physician in any way relating to

417 adverse determinations.

418 (11) Notice of an adverse determination shall be provided

419 by electronic mail to the health care provider that initiated

420 the prior authorization and to the patient. Notice required

421 under this subsection must include:

422 (a) The name, title, e-mail address, and telephone number

423 of the physician responsible for making the adverse

424 determination.

425 (b) The written clinical criteria, if any, and any

426 internal rule, guideline, or protocol on which the utilization

427 review entity relied when making the adverse determination and

428 how those provisions apply to the patient's specific medical

429 circumstance.

430 (c) Information for the patient and the patient's health

431 care provider which describes the procedure through which the

432 patient or health care provider may request a copy of any report

433 developed by personnel performing the review that led to the

434 adverse determination.

435 (d) Information that explains to the patient and the

436 patient's health care provider how to appeal the adverse

437 determination.

438 (12) If a utilization review entity requires prior

439 authorization of a nonurgent health care service, the

440 utilization review entity shall grant a prior authorization or

441 make an adverse determination and notify the patient and the

442 patient's health care provider of the decision within 72 hours

443 after obtaining all necessary information to grant the prior

444 authorization or make the adverse determination. For purposes of

445 this subsection, the term "necessary information" includes the

446 results of any face-to-face clinical evaluation or second

447 opinion that may be required.

448 (13) A utilization review entity shall grant an expedited

449 prior authorization or make an expedited adverse determination

450 concerning an urgent health care service and notify the patient

451 and the patient's health care provider of such expedited prior

452 authorization or adverse determination no later than 24 hours

453 after receiving all information needed to complete the review of

454 the requested urgent health care service.

455 (14)(a) A utilization review entity is prohibited from

456 requiring prior authorization for:

457 1. Prehospital transportation;

458 2. Provision of an emergency health care service; or

459 3. Provision of a service to a patient who is experiencing

460 an emergency medical condition.

461 (b) A utilization review entity is prohibited from

462 conducting utilization review activity, and from making any

463 adverse determinations, to the extent restricted or prohibited

464 by an agreement with a health care provider. A utilization

465 review entity is prohibited from performing any utilization

466 review activity, and from making any adverse determinations,

467 with respect to:

468 1. An emergency health care service; or

469 2. A service provided to a patient who experiences an

470 emergency medical condition.

471 (15) A utilization review entity is prohibited from

472 requiring prior authorization, and from making any adverse

473 determinations, for the provision of medications for opioid use

474 disorder. For purposes of this subsection, the term "medications

475 for opioid use disorder" means the use of medications, commonly

476 prescribed in combination with counseling and behavioral

477 therapies, to provide a comprehensive approach to the treatment

478 of opioid use disorder. FDA-approved medications used to treat

479 opioid addiction include, but are not limited to, methadone,

480 buprenorphine, alone or in combination with naloxone, and

481 extended-release injectable naltrexone. Types of behavioral

482 therapies include, but are not limited to, individual therapy,

483 group counseling, family behavior therapy, motivational

484 incentives, and other modalities.

485 (16) A utilization review entity is prohibited from

486 revoking, limiting, conditioning, or restricting a prior

487 authorization if care is provided within 45 business days after

488 the date the health care provider receives the prior

489 authorization. A utilization review entity must pay, or cause

490 payment to be made to, the health care provider, without any

491 prepayment review or prepayment audit before such payment, at

492 the contracted payment rate for a health care service provided

493 by the health care provider per the prior authorization, unless:

494 (a) The health care provider knowingly and materially

495 misrepresented the health care service in the prior

496 authorization request with the specific intent to deceive and

497 obtain an unlawful payment from the utilization review entity;

498 (b) The health care service was no longer a covered

499 benefit, and medical necessity did not constitute a basis for

500 such noncovered benefit status, on the day the health care

501 service was provided, and the utilization review entity notified

502 the health care provider in writing of these facts before the

503 health care service being provided;

504 (c) The authorized service was never performed; or

505 (d) The patient was no longer enrolled under the

506 applicable health plan and, on that basis, was not eligible for

507 health care coverage from the applicable health insurer or self-

508 insured plan on the day the care was provided, and the

509 utilization review entity notified the health care provider in

510 writing of these facts before the health care service being

511 provided.

512 (17) If a utilization review entity requires a prior

513 authorization for a health care service for the treatment of a

514 chronic or long-term care condition, the prior authorization

515 shall remain valid for the length of the treatment and the

516 utilization review entity is prohibited from requiring the

517 patient to obtain a prior authorization again for the health

518 care service.

519 (18) A utilization review entity is prohibited from

520 imposing an additional prior authorization requirement with

521 respect to a surgical or otherwise invasive procedure, or any

522 item furnished as part of the surgical or invasive procedure, if

523 the procedure or item is furnished during the perioperative

524 period of another procedure for which prior authorization was

525 granted by the health insurer.

526 (19) If there is a change in coverage or approval criteria

527 for a previously authorized health care service, the change in

528 coverage or approval criteria is prohibited from adversely

529 affecting an enrollee who received prior authorization before

530 the effective date of the change for the remainder of the

531 enrollee's plan year.

532 (20) A utilization review entity shall continue to honor a

533 prior authorization it has granted to an enrollee when the

534 enrollee changes products under the same health insurer.

535 (21) Any failure by a utilization review entity to comply

536 with the deadlines and other requirements specified in this

537 section shall result in any health care services subject to

538 review to be automatically deemed authorized by the utilization

539 review entity.

540 (22) Except as otherwise provided in paragraphs (16)(a)-

541 (d), prior authorization constitutes a conclusive determination

542 of the medical necessity of the authorized health care service

543 and an irrevocable obligation to pay for such authorized health

544 care service.

545 (23)(a) This section prohibits an agreement with a health

546 care provider to restrict, limit, prohibit, or substitute a

547 utilization review activity or prior authorization.

548 (b) Nothing in this section shall be construed to:

549 1. Limit in any way the restrictions or prohibitions on

550 adverse determinations under an agreement with a health care

551 provider, nor to imply permission for, or applicability of,

552 adverse determinations for emergency health care services.

553 2. Restrict, limit, or prohibit in any way prior

554 authorizations under an agreement between a provider and a

555 utilization review entity, nor to restrict, limit, or prohibit a

556 provider's rights to contest, reject, or oppose any prior

557 authorization activities.

558 (24) In the instance of a violation of this section, a

559 provider shall have a private cause of action to proceed against

560 the health insurer or utilization review entity in the

561 applicable tribunal for the violation.

562 Section 3. Section 627.6131, Florida Statutes, is amended

563 to read:

564 627.6131 Prompt payment of claims.—

565 (1) The contract shall include the following provision:

566 "Time of Payment of Claims: After receiving written proof of

567 loss, the health insurer shall ~~will~~ pay monthly all claims.

568 Claims ~~benefits then due for ...(type of benefit).... Benefits~~

569 for any other loss covered by this policy shall ~~will~~ be paid as

570 soon as the health insurer receives proper written proof."

571 (2) As used in this section, the term:

572 (a) "Claim" for a noninstitutional provider means a paper

573 HCFA 1500 claim form, or its successor, or an electronic billing

574 instrument submitted to the health insurer's designated location

575 that consists of the ANSI ASC X12N 837P standard ~~HCFA 1500~~ data

576 set, or its successor, that has all mandatory entries for a

577 physician licensed under chapter 458, chapter 459, chapter 460,

578 chapter 461, or chapter 463, or psychologists licensed under

579 chapter 490 or any appropriate billing instrument as designated

580 by the provider that has all mandatory entries for any other

581 noninstitutional provider. For institutional providers, "claim"

582 means a paper CMS-1450 claim form or its successor, or an

583 electronic billing instrument submitted to the health insurer's

584 designated location that consists of the ANSI ASC X12N 837I

585 standard ~~UB-92 data~~ set, or its successor, with entries stated

586 as mandatory by the National Uniform Billing Committee.

587 (b) "Clean claim" means a completed form, or completed

588 electronic billing instrument, containing all information

589 required under the applicable form or electronic billing

590 instrument, as well as information reasonably required by the

591 health insurer, other than for emergency services and care as

592 defined in s. 395.002(9), in advance of the provision of service

593 by the health insurer to substantiate the claim.

594 (c) "Electronic medical record" means the digital record

595 of a patient's information that may be accessed through

596 electronic means, via portal or other method of electronic

597 access, which may include information regarding the patient's

598 medical history, medical condition, medical treatment,

599 laboratory results, diagnostic reports, and clinical notes.

600 (d) "Emergency health care services" has the same meaning

601 as "emergency services and care" as defined in s. 395.002(9).

602 (e) "Health insurer" means any entity that offers health

603 insurance coverage, whether through a fully insured plan or a

604 self-insured plan or fund, including, as applicable:

605 1. An authorized health insurer offering health insurance

606 as defined in s. 624.603, as well as any entity that offers a

607 commercial self-insurance fund as defined in s. 624.462(2) or a

608 group self-insurance fund as described in s. 624.4621.

609 2. A health insurer that is subject to any of the

610 provisions of this chapter, as well as any entity that offers a

611 self-insurance plan or a group self-insurance plan.

612 (f) "Insured ineligibility" means that the insured was no

613 longer enrolled in the health plan at the time of receiving the

614 applicable service.

615 (g) "Overpayment" means payment made upon a claim that is:

616 1. Billed in error;

617 2. A duplicate claim; or

618 3. Billed for a service rendered to a patient in spite of

619 insured ineligibility.

621 A request for overpayment is limited to a billing error,

622 duplicate bill, or insured ineligibility.

623 (3) All claims for payment or overpayment, whether

624 electronic or nonelectronic:

625 (a) Are considered received on the date the claim is

626 received by the health insurer at its designated claims-receipt

627 location or the date the ~~claim for~~ overpayment claim is received

628 by the provider at its designated location.

629 (b) As to providers' claims for payment, must be mailed or

630 electronically transferred to the primary health insurer within

631 6 months after the following have occurred:

632 1. Discharge for inpatient services or the date of service

633 for outpatient services; and

634 2. The provider has been furnished with the correct name

635 and address of the patient's health insurer.

637 All providers' claims for payment, whether electronic or

638 nonelectronic, must be mailed or electronically transferred to

639 the secondary health insurer within 45 90 days after final

640 determination by the primary health insurer. A provider's claim

641 is considered submitted on the date it is electronically

642 transferred or mailed.

643 (c) Must not duplicate a claim previously submitted unless

644 it is determined that the original claim was not received or is

645 otherwise lost.

646 (4) For all electronically submitted claims, a health

647 insurer shall:

648 (a) Within 24 hours after the beginning of the next

649 business day after receipt of the claim, provide to the

650 electronic source submitting the claim an electronic

651 acknowledgment of the receipt of the claim, accompanied by a

652 statement indicating the health insurer's position as to whether

653 the claim is a clean claim or is missing any information that is

654 required under the applicable electronic billing instrument, as

655 described in paragraph (2)(a), or that was reasonably required

656 by the health insurer, other than for emergency health care

657 services, in advance of the provision of service to substantiate

658 ~~to the electronic source submitting~~ the claim, and the health

659 insurer asserts is missing as of the date of service.

660 (b) Within 15 20 days after receipt of the claim, pay the

661 claim or notify a provider or designee if a claim is denied or

662 contested. Notice of the health insurer's action on the claim

663 and payment of the claim is considered to be made on the date

664 the notice or payment was received by the provider ~~mailed~~ or

665 electronically transferred.

666 (c)1. Notification of the health insurer's determination

667 of a contested claim must be accompanied by an itemized list of

668 any ~~additional~~ information that is required under the applicable

669 billing instrument, as described in paragraph (2)(a), or that

670 was reasonably required by the health insurer, other than for

671 emergency health care services, in advance of the provision of

672 service to substantiate the claim, and the health insurer

673 asserts is missing as of the date of such service ~~or documents~~

674 ~~the insurer can reasonably determine are necessary to process~~

675 ~~the claim.~~

676 2. A provider must submit the additional information or

677 documentation, as specified on the itemized list, within 30 35

678 days after receipt of the notification of contestation unless,

679 within the 30-day period, the provider notifies the health

680 insurer of the provider's position that a clean claim has been

681 submitted. Additional information is considered submitted on the

682 date it is electronically transferred or mailed. The health

683 insurer is prohibited from requesting ~~may not request~~ duplicate

684 documents.

685 (d) For purposes of this subsection, electronic means of

686 transmission of claims, notices, documents, forms, and payments

687 shall be used to the greatest extent possible by the health

688 insurer and the provider.

689 (e) A claim that was contested by the health insurer must

690 be paid or denied within 30 90 days after receipt of the

691 additional information requested ~~claim.~~ Failure to pay or deny a

692 claim within 90 ~~120~~ days after receipt of the claim, regardless

693 of whether contested by the health insurer, creates an

694 uncontestable obligation to pay the claim as submitted by the

695 provider.

696 (5) For all nonelectronically submitted claims, a health

697 insurer shall:

698 (a) Within 15 days following receipt of the claim

699 ~~Effective November 1, 2003,~~ provide to the provider or its

700 designee:

701 1. An acknowledgment of receipt of the claim, accompanied

702 by a statement indicating the health insurer's position as to

703 whether the claim is a clean claim or the claim is missing any

704 information that is required under the applicable paper billing

705 form, as described in paragraph (2)(a), or that was reasonably

706 required by the health insurer, other than for emergency health

707 care services, in advance of the provision of service to

708 substantiate the claim, and the health insurer asserts is

709 missing as of the date of service; or

710 2. ~~within 15 days after receipt of the claim to the~~

711 ~~provider or provide a provider within 15 days after receipt with~~

712 Electronic access to the status of the a submitted claim, which

713 status must indicate the health insurer's position as to whether

714 the claim is a clean claim or missing any information described

715 in subparagraph 1.

716 (b) Within 30 40 days after receipt of the claim, pay the

717 claim or notify a provider or designee if a claim is denied or

718 contested. Notice of the health insurer's action on the claim

719 and payment of the claim is considered to be made on the date

720 the notice or payment was received by the provider ~~mailed~~ or

721 electronically transferred.

722 (c)1. Notification of the health insurer's determination

723 of a contested claim must be accompanied by an itemized list of

724 any ~~additional~~ information that is required under the applicable

725 form or billing instrument, as described in paragraph (2)(a), or

726 that was reasonably required by the health insurer, other than

727 for emergency health care services, in advance of the provision

728 of service to substantiate the claim, and the health insurer

729 asserts is missing as of the date of such service ~~or documents~~

730 ~~the insurer can reasonably determine are necessary to process~~

731 ~~the claim.~~

732 2. A provider must submit the additional information or

733 documentation, as specified on the itemized list, within 30 35

734 days after receipt of the notification of contestation unless,

735 within the 30-day period, the provider notifies the health

736 insurer of its position that a clean claim has been submitted.

737 Additional information is considered submitted on the date it is

738 electronically transferred or mailed. The health insurer is

739 prohibited from requesting ~~may not request~~ duplicate documents.

740 (d) For purposes of this subsection, electronic means of

741 transmission of claims, notices, documents, forms, and payments

742 shall be used to the greatest extent possible by the health

743 insurer and the provider.

744 (e) A claim that was contested by the health insurer must

745 be paid or denied within 30 ~~120~~ days after receipt of the

746 additional information requested ~~claim.~~ Failure to pay or deny a

747 claim within 90 ~~140~~ days after receipt of the claim, regardless

748 of whether contested by the health insurer, creates an

749 uncontestable obligation to pay the claim as submitted by the

750 provider.

751 (6) Regardless of whether a claim has been submitted

752 electronically or nonelectronically, and notwithstanding any

753 other provision of this section to the contrary:

754 (a) Once a provider grants a health insurer access to a

755 patient's electronic medical record, the provider shall be

756 deemed to have supplied all information necessary to pay the

757 claim, including, without limitation, all information that is

758 required under the applicable billing instrument and that was

759 reasonably required by the health insurer, other than for

760 emergency health care services, in advance of the provision of

761 service to substantiate the claim. Additional information or

762 documentation, regardless of whether the health insurer requests

763 any additional information, shall be deemed unnecessary, and

764 deemed not required for payment of the claim, and any request

765 for additional information, and any position of the health

766 insurer or any third party acting on behalf of the health

767 insurer regarding any lack of information from the provider, is

768 prohibited from being used to deny, reduce, offset, withhold,

769 pend, or delay payment of the claim.

770 (b) For instances in which notice of access to the

771 electronic medical record has been provided to the health

772 insurer, the claim must be paid or denied within 30 days of such

773 notice to the health insurer. Failure to pay or deny a claim,

774 for which the health insurer has been provided notice of access

775 to the electronic medical record within 75 days after receipt of

776 such notice creates an uncontestable obligation to pay the claim

777 as submitted by the provider.

778 (7)(6) If a health insurer determines that it has made an

779 overpayment to a provider for services rendered to an insured,

780 the health insurer must make an overpayment a claim for such

781 overpayment to the provider's designated location. A health

782 insurer that makes an overpayment a claim ~~for overpayment~~ to a

783 provider under this section shall give the provider a written or

784 electronic statement specifying the basis for the retrospective

785 ~~retroactive~~ denial or payment adjustment. The health insurer

786 must also identify the claim or claims, or portion thereof, as

787 to which the health insurer alleges overpayment claim; and the

788 specific invoice number submitted with or on the claim ~~portion~~

789 ~~thereof, for which a claim for overpayment is submitted.~~ Except

790 as provided in subparagraph (a).3, there shall be no denial,

791 reduction, offset, withholding, pending, or delay of payment, or

792 other negative impact, regardless of whether by the health

793 insurer or any third party acting on behalf of such health

794 insurer, on payment of any other claim of the provider on the

795 basis of the overpayment allegation.

796 (a) If an overpayment determination is the result of

797 retrospective ~~retroactive~~ review or retrospective audit of

798 ~~coverage decisions or payment levels not related to fraud,~~ a

799 health insurer shall adhere to the following procedures:

800 1. All overpayment claims ~~for overpayment~~ must be received

801 by the ~~submitted to a~~ provider within 18 30 months after the

802 health insurer's payment of the claim. A provider must pay,

803 deny, or contest the health insurer's ~~claim for~~ overpayment

804 claim within 40 days after the receipt of the overpayment claim.

805 All contested overpayment claims ~~for overpayment~~ must be paid or

806 denied within 120 days after receipt of the overpayment claim.

807 Failure to pay or deny an overpayment ~~and~~ claim within 140 days

808 after receipt creates an uncontestable obligation to pay the

809 overpayment claim.

810 2. A provider that denies or contests a health insurer's

811 overpayment claim ~~for overpayment~~ or any portion of an

812 overpayment a claim shall notify the health insurer, in writing,

813 within 40 35 days after the provider receives the overpayment

814 claim that such overpayment ~~the~~ claim ~~for overpayment~~ is

815 contested or denied. The notice that the overpayment claim ~~for~~

816 ~~overpayment~~ is denied or contested must identify the denied or

817 contested portion of the overpayment claim and the specific

818 reason for contesting or denying the overpayment claim and, if

819 contested, must include a request for additional information. If

820 the health insurer submits additional information, the health

821 insurer must, within 35 days after receipt of the request, mail

822 or electronically transfer the information to the provider. The

823 provider shall pay or deny the overpayment claim ~~for overpayment~~

824 within 45 days after receipt of the information. The notice from

825 the provider regarding denial or contestation of the overpayment

826 claim is considered made on the date the notice is mailed or

827 electronically transferred by the provider.

828 3. The health insurer is prohibited from denying,

829 reducing, offsetting, withholding, pending, or delaying ~~may not~~

830 ~~reduce~~ payment to the provider for other services unless the

831 provider agrees to the denial, reduction, offset, withholding,

832 pending, or delay of payment in writing or fails to respond to

833 the health insurer's overpayment claim as required by this

834 paragraph.

835 4. Payment of an overpayment claim is considered made on

836 the date the payment was mailed or electronically transferred.

837 An overdue payment of a claim bears simple interest at the rate

838 of 12 percent per year. Interest on an overdue payment for an

839 overpayment a claim ~~for an overpayment~~ begins to accrue when the

840 overpayment claim should have been paid, ~~denied, or contested.~~

841 (b) An overpayment A claim is prohibited ~~for overpayment~~

842 ~~shall not be permitted~~ beyond 18 30 months after the health

843 insurer's payment of a claim, except that overpayment claims ~~for~~

844 ~~overpayment~~ may be sought beyond that time from providers

845 convicted of fraud pursuant to s. 817.234.

846 (8)(7) Payment of a claim is considered made on the date

847 the payment was mailed or electronically transferred. An overdue

848 payment of a claim bears simple interest of 15 12 percent per

849 year, to be calculated upon the full total amount that should

850 have been paid on the claim within the applicable time period

851 specified in this section. If an applicable court, arbitration

852 tribunal, or other binding legal process determines that a claim

853 that was paid at a lesser amount should have been paid at a full

854 total amount, whether under a breach of contract legal claim, a

855 legal claim under a statutory private cause of action, or other

856 basis, the 15 percent per year interest shall be calculated upon

857 the full total amount, rather than upon the difference between

858 the full total amount and the amount that was actually paid. If

859 an applicable court, arbitration tribunal, or other binding

860 legal process determines that a claim was subject to an

861 inappropriate or impermissible denial or partial denial, whether

862 in a breach of contract, statute, common law, or otherwise,

863 interest shall be calculated upon the full total amount that

864 should have been paid on the claim within the applicable time

865 period for payment specified in this section, and the act of

866 denial or partial denial shall be deemed not to have in any way

867 tolled the time period for such payment. Interest on the full

868 total amount that should have been paid on the claim within the

869 applicable time period specified in this section ~~an overdue~~

870 ~~payment for a claim or for any portion of a claim~~ begins to

871 accrue when the claim should have been paid, ~~denied, or~~

872 ~~contested.~~ The interest must be paid along with, and in addition

873 to, the payment for the satisfaction of the full total amount of

874 the claim, as determined by an applicable court, arbitration

875 tribunal, or other binding legal process ~~is payable with the~~

876 ~~payment of the claim.~~

877 (9)(8) For all contracts entered into or renewed on or

878 after October 1, 2002, a health insurer's internal dispute

879 resolution process related to a denied claim not under active

880 review by a mediator, arbitrator, or third-party dispute entity

881 must be finalized within 60 days after the receipt of the

882 provider's request for review or appeal. Notwithstanding any

883 provision of this section to the contrary, when the provider and

884 health insurer disagree as to interpretation of contractual or

885 statutory language, the provider is not required to participate

886 in the health insurer's internal dispute resolution process.

887 (10)(9) A provider or any representative of a provider,

888 regardless of whether the provider is under contract with the

889 health insurer, is prohibited from collecting or attempting ~~may~~

890 ~~not collect or attempt~~ to collect money from, maintaining

891 ~~maintain~~ any action at law against, or reporting ~~report~~ to a

892 credit agency an insured for payment of covered services for

893 which the health insurer contested or denied the provider's

894 claim. This prohibition applies during the pendency of any claim

895 for payment made by the provider to the health insurer for

896 payment of the services or internal dispute resolution process

897 to determine whether the health insurer is liable for the

898 services. For a claim, this pendency applies from the date the

899 claim or a portion of the claim is denied to the date of the

900 completion of the health insurer's internal dispute resolution

901 process, not to exceed 60 days. This subsection does not

902 prohibit the collection by the provider of copayments,

903 coinsurance, or deductible amounts due the provider.

904 ~~(10) The provisions of this section may not be waived,~~

905 ~~voided, or nullified by contract.~~

906 (11) A health insurer is prohibited from retrospectively

907 denying ~~may not retroactively deny~~ a claim because of insured

908 ineligibility more than 90 days ~~1 year~~ after the date of payment

909 of the claim.

910 (12) A health insurer shall pay a contracted primary care

911 or admitting physician, pursuant to such physician's contract,

912 for providing inpatient services in a contracted hospital to an

913 insured if such services are determined by such physician ~~the~~

914 ~~health insurer~~ to be medically necessary and, regardless of the

915 health plan's determination of medical necessity, are otherwise

916 covered services under the health insurer's contract with the

917 contract holder.

918 (13) Upon written notification by an insured, a health an

919 insurer shall investigate any claim of improper billing of the

920 insured by a physician, hospital, or other health care provider

921 for a health care service alleged to not actually have been

922 received. The health insurer shall determine if the insured

923 actually received the applicable service ~~was properly billed for~~

924 ~~only those procedures and services that the insured actually~~

925 ~~received.~~ If the health insurer determines that the insured did

926 not actually receive the applicable service ~~has been improperly~~

927 ~~billed,~~ the health insurer shall notify the insured and the

928 provider of its findings and shall reduce the amount of payment

929 to the provider by the amount for the service that was not

930 actually received ~~determined to be improperly billed. If a~~

931 ~~reduction is made due to such notification by the insured, the~~

932 ~~insurer shall pay to the insured 20 percent of the amount of the~~

933 ~~reduction up to $500.~~

934 (14) A permissible error ratio of 5 percent is established

935 for health insurer's claims payment violations of paragraphs

936 (4)(a), (b), (c), and (e) and (5)(a), (b), (c), and (e). If the

937 error ratio of a particular health insurer does not exceed the

938 permissible error ratio of 5 percent for an audit period, no

939 fine shall be assessed for the noted claims violations for the

940 audit period. The error ratio shall be determined by dividing

941 the number of claims with violations found on a statistically

942 valid sample of claims for the audit period by the total number

943 of claims in the sample. If the error ratio exceeds the

944 permissible error ratio of 5 percent, a fine may be assessed

945 according to s. 624.4211 for those claims payment violations

946 which exceed the error ratio. Notwithstanding the provisions of

947 this section, the office may fine a health insurer for claims

948 payment violations of paragraphs (4)(e) and (5)(e) which create

949 an uncontestable obligation to pay the claim as submitted by the

950 provider. The office shall refrain from imposing a ~~not~~ fine upon

951 a health insurer ~~insurers~~ for violations which the office

952 determines were due to circumstances beyond the health insurer's

953 control.

954 (15) This section is applicable only to a major medical

955 expense health insurance policy as defined in s. 627.643(2)(e)

956 offered by a group or an individual health insurer licensed

957 under ~~pursuant to~~ chapter 624, including a preferred provider

958 policy under s. 627.6471 and an exclusive provider organization

959 under s. 627.6472 or a group or individual insurance contract

960 that only provides direct payments to dentists for enumerated

961 dental services, or other health insurance coverage, policy, or

962 fund, regardless of whether fully insured or self-insured,

963 offered or administered by a health insurer.

964 (16) Notwithstanding paragraph (4)(b), where an electronic

965 pharmacy claim is submitted to a pharmacy benefits manager

966 acting on behalf of a health insurer, the pharmacy benefits

967 manager shall, within 30 days of receipt of the claim, pay the

968 claim or notify a provider or designee if a claim is denied or

969 contested. Notice of the health insurer's action on the claim

970 and payment of the claim is considered to be made on the date

971 the notice or payment was received by the provider ~~mailed~~ or

972 electronically transferred.

973 (17) Notwithstanding paragraph (5)(a), effective November

974 1, 2003, where a nonelectronic pharmacy claim is submitted to a

975 pharmacy benefits manager acting on behalf of a health insurer,

976 the pharmacy benefits manager shall provide acknowledgment of

977 receipt of the claim within 30 days after receipt of the claim

978 to the provider or provide a provider within 30 days after

979 receipt with electronic access to the status of a submitted

980 claim.

981 (18) Notwithstanding the 18-month ~~30-month~~ period provided

982 in subsection (7) ~~(6),~~ all overpayment claims ~~for overpayment~~

983 submitted to a provider licensed under chapter 395, chapter 458,

984 chapter 459, chapter 460, chapter 461, chapter 463, chapter 466,

985 or chapter 490 must be submitted to the provider within 12

986 months after the health insurer's payment of the claim. An

987 overpayment A claim to a provider licensed under chapter 395,

988 chapter 458, chapter 459, chapter 460, chapter 461, chapter 463,

989 chapter 466, or chapter 490 is prohibited ~~for overpayment may~~

990 ~~not be permitted~~ beyond 12 months after the health insurer's

991 payment of a claim, except that overpayment claims ~~for~~

992 ~~overpayment~~ may be sought beyond that time from providers

993 convicted of fraud pursuant to s. 817.234.

994 (19) Notwithstanding any other provision of this section,

995 all claims for underpayment from a provider licensed under

996 chapter 395, chapter 458, chapter 459, chapter 460, chapter 461,

997 or chapter 466 must be submitted to the health insurer within 12

998 months after the health insurer's payment of the claim. A claim

999 for underpayment by a provider licensed under chapter 395,

1000 chapter 458, chapter 459, chapter 460, chapter 461, or chapter

1001 466 is prohibited ~~may not be permitted~~ beyond 12 months after

1002 the health insurer's payment of a claim.

1003 (20) Nothing in this section shall be interpreted to

1004 limit, restrict, or negatively impact any legal claim by a

1005 provider or health insurer for breach of contract, statutory or

1006 regulatory violation, or a common-law cause of action, nor to

1007 shorten or otherwise negatively impact the statute of

1008 limitations timeframe for bringing any such legal claim.

1009 (21) A health insurer is prohibited from requesting

1010 information from a contracted or noncontracted provider which

1011 does not apply to the medical condition at issue for the

1012 purposes of adjudicating a clean claim.

1013 (22) A health insurer is prohibited from requesting a

1014 contracted or noncontracted provider to resubmit claim

1015 information that the contracted or noncontracted provider can

1016 document it has already provided to the health insurer or that

1017 is contained inside the electronic medical record to which the

1018 health insurer has been provided access.

1019 (23) Notwithstanding any other provision of this section

1020 to the contrary, a health insurer is prohibited from requiring

1021 any information from a provider before the provision of

1022 emergency health care services as a condition of payment of a

1023 claim, as a basis for denying, delaying, offsetting,

1024 withholding, or reducing payment of a claim, or in contesting

1025 whether the claim is a clean claim.

1026 (24) In an instance of a violation of this section, a

1027 provider shall have a private cause of action to proceed against

1028 the health insurer in the applicable tribunal for the violation.

1029 (25)(20)(a) A contract between a health insurer and a

1030 dentist licensed under chapter 466 for the provision of services

1031 to an insured is prohibited from specifying ~~may not specify~~

1032 credit card payment as the only acceptable method for payments

1033 from the health insurer to the dentist.

1034 (b) When a health insurer employs the method of claims

1035 payment to a dentist through electronic funds transfer,

1036 including, but not limited to, virtual credit card payment, the

1037 health insurer shall notify the dentist as provided in this

1038 paragraph and obtain the dentist's consent before employing the

1039 electronic funds transfer. The dentist's consent described in

1040 this paragraph applies to the dentist's entire practice. For the

1041 purpose of this paragraph, the dentist's consent, which may be

1042 given through e-mail, must bear the signature of the dentist.

1043 Such signature includes an electronic or digital signature if

1044 the form of signature is recognized as a valid signature under

1045 applicable federal law or state contract law or an act that

1046 demonstrates express consent, including, but not limited to,

1047 checking a box indicating consent. The health insurer or dentist

1048 is prohibited from requiring ~~may not require~~ that a dentist's

1049 consent as described in this paragraph be made on a patient-by-

1050 patient basis. The notification provided by the health insurer

1051 to the dentist must include all of the following:

1052 1. The fees, if any, associated with the electronic funds

1053 transfer.

1054 2. The available methods of payment of claims by the

1055 health insurer, with clear instructions to the dentist on how to

1056 select an alternative payment method.

1057 (c) A health insurer that pays a claim to a dentist

1058 through automated clearinghouse transfer is prohibited from

1059 charging ~~may not charge~~ a fee solely to transmit the payment to

1060 the dentist unless the dentist has consented to the fee.

1061 (d) This subsection applies to contracts delivered,

1062 issued, or renewed on or after January 1, 2025.

1063 (e) The office has all rights and powers to enforce this

1064 subsection as provided by s. 624.307.

1065 (f) The commission may adopt rules to implement this

1066 subsection.

1067 (26)(21)(a) A health insurer is prohibited from denying

1068 ~~may not deny~~ any claim subsequently submitted by a dentist

1069 licensed under chapter 466 for procedures specifically included

1070 in a prior authorization unless at least one of the following

1071 circumstances applies for each procedure denied:

1072 1. Benefit limitations, such as annual maximums and

1073 frequency limitations not applicable at the time of the prior

1074 authorization, are reached subsequent to issuance of the prior

1075 authorization.

1076 2. The documentation provided by the person submitting the

1077 claim fails to support the claim as originally authorized.

1078 3. Subsequent to the issuance of the prior authorization,

1079 new procedures are provided to the patient or a change in the

1080 condition of the patient occurs such that the prior authorized

1081 procedure would no longer be considered medically necessary,

1082 based on the prevailing standard of care.

1083 4. Subsequent to the issuance of the prior authorization,

1084 new procedures are provided to the patient or a change in the

1085 patient's condition occurs such that the prior authorized

1086 procedure would at that time have required disapproval pursuant

1087 to the terms and conditions for coverage under the patient's

1088 plan in effect at the time the prior authorization was issued.

1089 5. The denial of the claim was due to one of the

1090 following:

1091 a. Another payor is responsible for payment.

1092 b. The dentist has already been paid for the procedures

1093 identified in the claim.

1094 c. The claim was submitted fraudulently, or the prior

1095 authorization was based in whole or material part on erroneous

1096 information provided to the health insurer by the dentist,

1097 patient, or other person not related to the health insurer.

1098 d. The person receiving the procedure was not eligible to

1099 receive the procedure on the date of service.

1100 e. The services were provided during the grace period

1101 established under s. 627.608 or applicable federal regulations,

1102 and the dental insurer notified the provider that the patient

1103 was in the grace period when the provider requested eligibility

1104 or enrollment verification from the dental insurer, if such

1105 request was made.

1106 (b) This subsection applies to all contracts delivered,

1107 issued, or renewed on or after January 1, 2025.

1108 (c) The office has all rights and powers to enforce this

1109 subsection as provided by s. 624.307.

1110 (d) The commission may adopt rules to implement this

1111 subsection.

1112 Section 4. Section 641.3155, Florida Statutes, is amended

1113 to read:

1114 641.3155 Prompt payment of claims.—

1115 (1) As used in this section, the term:

1116 (a) "Claim" for a noninstitutional provider means a paper

1117 HCFA 1500 claim form, or its successor, or an electronic billing

1118 instrument submitted to the health maintenance organization's

1119 designated location that consists of the ANSI ASC X12N 837P

1120 standard ~~HCFA 1500~~ data set, or its successor, that has all

1121 mandatory entries for a physician licensed under chapter 458,

1122 chapter 459, chapter 460, chapter 461, or chapter 463, or

1123 psychologists licensed under chapter 490 or any appropriate

1124 billing instrument as designated by the provider that has all

1125 mandatory entries for any other noninstitutional provider. For

1126 institutional providers, "claim" means a paper CMS-1450 claim

1127 form, or its successor, or an electronic billing instrument

1128 submitted to the health maintenance organization's designated

1129 location that consists of the ANSI ASC X12N 837I standard ~~UB-92~~

1130 data set or its successor with entries stated as mandatory by

1131 the National Uniform Billing Committee.

1132 (b) "Clean claim" means a completed form, or completed

1133 electronic billing instrument, containing all information

1134 required under the applicable form or electronic billing

1135 instrument, as well as information reasonably required by the

1136 health maintenance organization, other than for emergency

1137 services and care as defined in s. 641.19, in advance of the

1138 provision of service by the health maintenance organization to

1139 substantiate the claim.

1140 (c) "Electronic medical record" means the digital record

1141 of a patient's information that may be accessed through

1142 electronic means, via portal or other method of electronic

1143 access, which may include information regarding the patient's

1144 medical history, medical condition, medical treatment,

1145 laboratory results, diagnostic reports, and clinical notes.

1146 (d) "Emergency health care service" has the same meaning

1147 as "emergency services and care" as defined in s. 641.19.

1148 (e) "Enrollee ineligibility" means that the enrollee was

1149 no longer enrolled in the health maintenance organization at the

1150 time of receiving the applicable service.

1151 (f) "Overpayment" means payment made upon a claim that is:

1152 1. Billed in error;

1153 2. A duplicate claim; or

1154 3. Billed for a service rendered to a patient in spite of

1155 enrollee ineligibility.

1157 A request for overpayment is limited to a billing error,

1158 duplicate bill, or enrollee ineligibility.

1159 (2) All claims for payment or overpayment, whether

1160 electronic or nonelectronic:

1161 (a) Are considered received on the date the claim is

1162 received by the health maintenance organization at its

1163 designated claims-receipt location or the date the overpayment a

1164 claim ~~for overpayment~~ is received by the provider at its

1165 designated location.

1166 (b) As to providers' claims for payment, must be mailed or

1167 electronically transferred to the primary organization within 6

1168 months after the following have occurred:

1169 1. Discharge for inpatient services or the date of service

1170 for outpatient services; and

1171 2. The provider has been furnished with the correct name

1172 and address of the patient's health maintenance organization.

1174 All providers' claims for payment, whether electronic or

1175 nonelectronic, must be mailed or electronically transferred to

1176 the secondary organization within 45 90 days after final

1177 determination by the primary organization. A provider's claim is

1178 considered submitted on the date it is electronically

1179 transferred or mailed.

1180 (c) Must not duplicate a claim previously submitted unless

1181 it is determined that the original claim was not received or is

1182 otherwise lost.

1183 (3) For all electronically submitted claims, a health

1184 maintenance organization shall:

1185 (a) Within 24 hours after the beginning of the next

1186 business day after receipt of the claim, provide to the

1187 electronic source submitting the claim an electronic

1188 acknowledgment of the receipt of the claim, accompanied by a

1189 statement indicating the health maintenance organization's

1190 position as to whether the claim is a clean claim or whether the

1191 claim is missing any information that is required under the

1192 applicable electronic billing instrument described in paragraph

1193 (1)(a) or that was reasonably required by the health maintenance

1194 organization, other than for emergency health care services, in

1195 advance of the provision of service to substantiate ~~to the~~

1196 ~~electronic source submitting~~ the claim, and the health

1197 maintenance organization asserts is missing as of the date of

1198 service.

1199 (b) Within 15 20 days after receipt of the claim, pay the

1200 claim or notify a provider or designee if a claim is denied or

1201 contested. Notice of the health maintenance organization's

1202 action on the claim and payment of the claim is considered to be

1203 made on the date the notice or payment was received by the

1204 provider ~~mailed~~ or electronically transferred.

1205 (c)1. Notification of the health maintenance

1206 organization's determination of a contested claim must be

1207 accompanied by an itemized list of any ~~additional~~ information

1208 required under the applicable billing instrument described in

1209 paragraph (1)(a) or that was reasonably required by the health

1210 maintenance organization, other than for emergency health care

1211 services, in advance of the provision of service to substantiate

1212 the claim, and the health maintenance organization asserts is

1213 missing as of the date of such service ~~or documents the insurer~~

1214 ~~can reasonably determine are necessary to process the claim.~~

1215 2. A provider must submit the additional information or

1216 documentation, as specified on the itemized list, within 30 35

1217 days after receipt of the notification of contestation unless,

1218 within the 30-day period, the provider notifies the health

1219 maintenance organization of the provider's position that a clean

1220 claim has been submitted. Additional information is considered

1221 submitted on the date it is electronically transferred or

1222 mailed. The health maintenance organization is prohibited from

1223 requesting ~~may not request~~ duplicate documents.

1224 (d) For purposes of this subsection, electronic means of

1225 transmission of claims, notices, documents, forms, and payment

1226 shall be used to the greatest extent possible by the health

1227 maintenance organization and the provider.

1228 (e) A claim that was contested by the health maintenance

1229 organization must be paid or denied within 30 90 days after

1230 receipt of the additional information requested ~~claim.~~ Failure

1231 to pay or deny a claim within 90 ~~120~~ days after receipt of the

1232 claim, regardless of whether contested by the health maintenance

1233 organization, creates an uncontestable obligation to pay the

1234 claim.

1235 (4) For all nonelectronically submitted claims, a health

1236 maintenance organization shall:

1237 (a) Within 15 days following receipt of the claim

1238 ~~Effective November 1, 2003,~~ provide to the provider, or

1239 designee, who submitted the claim:

1240 1. An acknowledgment of receipt of the claim, accompanied

1241 by a statement indicating the health maintenance organization's

1242 position as to whether the claim is a clean claim or the claim

1243 is missing any information that is required under the applicable

1244 paper billing form, as described in paragraph (1)(a), or that

1245 was reasonably required by the health maintenance organization,

1246 other than for emergency health care services, in advance of the

1247 provision of service to substantiate the claim, and the health

1248 maintenance organization asserts is missing as of the date of

1249 service; or

1250 2. ~~within 15 days after receipt of the claim to the~~

1251 ~~provider or designee or provide a provider or designee within 15~~

1252 ~~days after receipt with~~ Electronic access to the status of the a

1253 submitted claim, which status must indicate the health

1254 maintenance organization's position as to whether the claim is a

1255 clean claim or missing any information described in subparagraph

1256 1.

1257 (b) Within 30 40 days after receipt of the claim, pay the

1258 claim or notify a provider or designee if a claim is denied or

1259 contested. Notice of the health maintenance organization's

1260 action on the claim and payment of the claim is considered to be

1261 made on the date the notice or payment was received by the

1262 provider ~~mailed~~ or electronically transferred.

1263 (c)1. Notification of the health maintenance

1264 organization's determination of a contested claim must be

1265 accompanied by an itemized list of any ~~additional~~ information

1266 required under the applicable form or billing instrument

1267 described in paragraph (1)(a), or that was reasonably required

1268 by the health maintenance organization, other than for emergency

1269 health care services, in advance of the provision of service to

1270 substantiate the claim, and the health maintenance organization

1271 asserts is missing as of the date of such service ~~or documents~~

1272 ~~the organization can reasonably determine are necessary to~~

1273 ~~process the claim.~~

1274 2. A provider must submit the additional information or

1275 documentation, as specified on the itemized list, within 30 35

1276 days after receipt of the notification of contestation unless,

1277 within the 30-day period, the provider notifies the health

1278 maintenance organization of the provider's position that a clean

1279 claim has been submitted. Additional information is considered

1280 submitted on the date it is electronically transferred or

1281 mailed. The health maintenance organization is prohibited from

1282 requesting ~~may not request~~ duplicate documents.

1283 (d) For purposes of this subsection, electronic means of

1284 transmission of claims, notices, documents, forms, and payments

1285 shall be used to the greatest extent possible by the health

1286 maintenance organization and the provider.

1287 (e) A claim that was contested by the health maintenance

1288 organization must be paid or denied within 30 ~~120~~ days after

1289 receipt of the additional information requested ~~claim.~~ Failure

1290 to pay or deny a claim within 90 ~~140~~ days after receipt of the

1291 claim, regardless of whether contested by the health maintenance

1292 organization, creates an uncontestable obligation to pay the

1293 claim as submitted by the provider.

1294 (5) Regardless of whether a claim has been submitted

1295 electronically or nonelectronically, and notwithstanding any

1296 other provision of this section to the contrary:

1297 (a) Once a provider grants a health maintenance

1298 organization access to a patient's electronic medical record,

1299 the provider shall be deemed to have supplied all information

1300 necessary to pay the claim, including, without limitation, all

1301 information that is required under the applicable billing

1302 instrument and that was reasonably required by the health

1303 maintenance organization, other than for emergency health care

1304 services, in advance of the provision of service to substantiate

1305 the claim. Additional information or documentation, regardless

1306 of whether the health maintenance organization requests any

1307 additional information, shall be deemed unnecessary, and deemed

1308 not required for payment of the claim, and any request for

1309 additional information, and any position of the health

1310 maintenance organization or any third party acting on behalf of

1311 the health maintenance organization regarding any lack of

1312 information from the provider, is prohibited from being used to

1313 deny, reduce, offset, withhold, pend, or delay payment of the

1314 claim.

1315 (b) For instances in which notice of access to the

1316 electronic medical record has been provided to the health

1317 maintenance organization, the claim must be paid or denied

1318 within 30 days of such notice to the health maintenance

1319 organization. Failure to pay or deny a claim, for which the

1320 health maintenance organization has been provided notice of

1321 access to the electronic medical record within 75 days after

1322 receipt of such notice creates an uncontestable obligation to

1323 pay the claim as submitted by the provider.

1324 (6)(5) If a health maintenance organization determines

1325 that it has made an overpayment to a provider for services

1326 rendered to an enrollee ~~a subscriber,~~ the health maintenance

1327 organization must make an overpayment a claim for such

1328 overpayment to the provider's designated location. A health

1329 maintenance organization that makes an overpayment a claim ~~for~~

1330 ~~overpayment~~ to a provider under this section shall give the

1331 provider a written or electronic statement specifying the basis

1332 for the retrospective ~~retroactive~~ denial or payment adjustment.

1333 The health maintenance organization must also identify the claim

1334 or claims, or ~~overpayment claim~~ portion thereof, as to which the

1335 health maintenance organization alleges overpayment; and the

1336 specific invoice number submitted with or on the claim, as well

1337 as the specific line items on the bill that are subject to the

1338 overpayment claim ~~for which a claim for overpayment is~~

1339 ~~submitted.~~ Except as provided in subparagraph (a)3., there shall

1340 be no denial, reduction, offset, withholding, pending, or delay

1341 of payment, or other negative impact, regardless of whether by

1342 the health maintenance organization or any third party acting on

1343 behalf of such health maintenance organization, on payment of

1344 any other claim of the provider on the basis of the overpayment

1345 allegation.

1346 (a) If an overpayment determination is the result of

1347 retrospective ~~retroactive~~ review or retrospective audit of

1348 ~~coverage decisions or payment levels not related to fraud,~~ a

1349 health maintenance organization shall adhere to the following

1350 procedures:

1351 1. All overpayment claims ~~for overpayment~~ must be received

1352 by the ~~submitted to a~~ provider within 18 30 months after the

1353 health maintenance organization's payment of the claim. A

1354 provider must pay, deny, or contest the health maintenance

1355 organization's overpayment claim ~~for overpayment~~ within 40 days

1356 after the receipt of the overpayment claim. All contested

1357 overpayment claims ~~for overpayment~~ must be paid or denied within

1358 120 days after receipt of the overpayment claim. Failure to pay

1359 or deny an overpayment ~~and~~ claim within 140 days after receipt

1360 creates an uncontestable obligation to pay the overpayment

1361 claim.

1362 2. A provider that denies or contests a health maintenance

1363 organization's overpayment claim ~~for overpayment~~ or any portion

1364 of an overpayment a claim shall notify the health maintenance

1365 organization, in writing, within 40 35 days after the provider

1366 receives the overpayment claim that the overpayment claim ~~for~~

1367 ~~overpayment~~ is contested or denied. The notice that the

1368 overpayment claim ~~for overpayment~~ is denied or contested must

1369 identify the denied or contested portion of the claim and the

1370 specific reason for contesting or denying the overpayment claim

1371 and, if contested, must include a request for additional

1372 information. If the health maintenance organization submits

1373 additional information, the health maintenance organization

1374 must, within 35 days after receipt of the request, mail or

1375 electronically transfer the information to the provider. The

1376 provider shall pay or deny the overpayment claim ~~for overpayment~~

1377 within 45 days after receipt of the information. The notice from

1378 the provider regarding denial or contestation of the overpayment

1379 claim is considered made on the date the notice is mailed or

1380 electronically transferred by the provider.

1381 3. The health maintenance organization is prohibited from

1382 denying, reducing, offsetting, withholding, pending, or delaying

1383 ~~may not reduce~~ payment to the provider for other services unless

1384 the provider agrees to the denial, reduction, offset,

1385 withholding, pending, or delay of payment in writing or fails to

1386 respond to the health maintenance organization's overpayment

1387 claim as required by this paragraph.

1388 4. Payment of an overpayment claim is considered made on

1389 the date the payment was mailed or electronically transferred.

1390 An overdue payment of a claim bears simple interest at the rate

1391 of 12 percent per year. Interest on an overdue payment for an

1392 overpayment a claim ~~for an overpayment payment~~ begins to accrue

1393 when the overpayment claim should have been paid, ~~denied, or~~

1394 ~~contested.~~

1395 (b) An overpayment A claim is prohibited ~~for overpayment~~

1396 ~~shall not be permitted~~ beyond 18 30 months after the health

1397 maintenance organization's payment of a claim, except that

1398 overpayment claims ~~for overpayment~~ may be sought beyond that

1399 time from providers convicted of fraud pursuant to s. 817.234.

1400 (7)(6) Payment of a claim is considered made on the date

1401 the payment was mailed or electronically transferred to the

1402 provider. An overdue payment of a claim bears simple interest of

1403 15 12 percent per year, to be calculated upon the full total

1404 amount that should have been paid on the claim within the

1405 applicable time period specified in this section. If an

1406 applicable court, arbitration tribunal, or other binding legal

1407 process determines that a claim that was paid at a lesser amount

1408 should have been paid at a full total amount, whether under a

1409 breach of contract legal claim, a legal claim under a statutory

1410 private cause of action, or other basis, the 15 percent per year

1411 interest shall be calculated upon the full total amount, rather

1412 than upon the difference between the full total amount and the

1413 amount that was actually paid. If an applicable court,

1414 arbitration tribunal, or other binding legal process determines

1415 that a claim was subject to an inappropriate or impermissible

1416 denial or partial denial, whether in a breach of contract,

1417 statute, common law, or otherwise, interest shall be calculated

1418 upon the full total amount that should have been paid on the

1419 claim within the applicable time period for payment specified in

1420 this section, and the act of denial or partial denial shall be

1421 deemed not to have in any way tolled the time period for such

1422 payment. Interest on the full total amount that should have been

1423 paid on the claim within the applicable time period specified in

1424 this section ~~an overdue payment for a claim or for any portion~~

1425 ~~of a claim~~ begins to accrue when the claim should have been

1426 paid, ~~denied, or contested.~~ The interest must be paid along

1427 with, and in addition to, the payment for the satisfaction of

1428 the full total amount of the claim, as determined by an

1429 applicable court, arbitration tribunal, or other binding legal

1430 process ~~is payable with the payment of the claim.~~

1431 (8)(7) For all contracts entered into or renewed on or

1432 after October 1, 2002, a health maintenance organization's

1433 internal dispute resolution process related to a denied claim

1434 not under active review by a mediator, arbitrator, or third-

1435 party dispute entity must be finalized within 60 days after the

1436 receipt of the provider's request for review or appeal.

1437 Notwithstanding any provision of this section to the contrary,

1438 if the provider and health maintenance organization disagree as

1439 to the interpretation of contractual or statutory language, the

1440 provider is not required to participate in the health

1441 maintenance organization's internal dispute resolution process.

1442 (9)(8) A provider or any representative of a provider,

1443 regardless of whether the provider is under contract with the

1444 health maintenance organization, is prohibited from collecting

1445 or attempting ~~may not collect or attempt~~ to collect money from,

1446 maintaining ~~maintain~~ any action at law against, or reporting

1447 ~~report~~ to a credit agency an enrollee ~~a subscriber~~ for payment

1448 of covered services for which the health maintenance

1449 organization contested or denied the provider's claim. This

1450 prohibition applies during the pendency of any claim for payment

1451 made by the provider to the health maintenance organization for

1452 payment of the services or internal dispute resolution process

1453 to determine whether the health maintenance organization is

1454 liable for the services. For a claim, this pendency applies from

1455 the date the claim or a portion of the claim is denied to the

1456 date of the completion of the health maintenance organization's

1457 internal dispute resolution process, not to exceed 60 days. This

1458 subsection does not prohibit collection by the provider of

1459 copayments, coinsurance, or deductible amounts due the provider.

1460 ~~(9) The provisions of this section may not be waived,~~

1461 ~~voided, or nullified by contract.~~

1462 (10) A health maintenance organization is prohibited from

1463 retrospectively denying ~~may not retroactively deny~~ a claim

1464 because of enrollee ~~subscriber~~ ineligibility more than 90 days 1

1465 ~~year~~ after the date of payment of the claim.

1466 (11) A health maintenance organization shall pay a

1467 contracted primary care or admitting physician, pursuant to such

1468 physician's contract, for providing inpatient services in a

1469 contracted hospital to an enrollee ~~a subscriber~~ if such services

1470 are determined by the primary care physician or admitting

1471 physician ~~health maintenance organization~~ to be medically

1472 necessary and such services are covered services under the

1473 health maintenance organization's contract with the contract

1474 holder.

1475 (12) A permissible error ratio of 5 percent is established

1476 for health maintenance organizations' claims payment violations

1477 of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c),

1478 and (e). If the error ratio of a particular health maintenance

1479 organization ~~insurer~~ does not exceed the permissible error ratio

1480 of 5 percent for an audit period, no fine shall be assessed for

1481 the noted claims violations for the audit period. The error

1482 ratio shall be determined by dividing the number of claims with

1483 violations found on a statistically valid sample of claims for

1484 the audit period by the total number of claims in the sample. If

1485 the error ratio exceeds the permissible error ratio of 5

1486 percent, a fine may be assessed according to s. 624.4211 for

1487 those claims payment violations which exceed the error ratio.

1488 Notwithstanding the provisions of this section, the office may

1489 fine a health maintenance organization for claims payment

1490 violations of paragraphs (3)(e) and (4)(e) which create an

1491 uncontestable obligation to pay the claim as submitted by the

1492 provider. The office shall refrain from imposing a ~~not~~ fine upon

1493 a health maintenance organization ~~organizations~~ for violations

1494 which the office determines were due to circumstances beyond the

1495 organization's control.

1496 (13) This section shall apply to all claims or any portion

1497 of a claim submitted for payment for services provided to an

1498 enrollee by a ~~health maintenance organization subscriber~~ under a

1499 health maintenance organization plan, or submitted for payment

1500 for services provided to an enrollee under a self-insured plan

1501 or fund, or fully-insured plan or fund, offered by a person or

1502 entity, when a health maintenance organization is involved in

1503 the administration, or claims-processing activities, relating to

1504 such plan or fund ~~subscriber contract to the organization for~~

1505 ~~payment.~~

1506 (14) Notwithstanding paragraph (3)(b), where an electronic

1507 pharmacy claim is submitted to a pharmacy benefits manager

1508 acting on behalf of a health maintenance organization, the

1509 pharmacy benefits manager shall, within 30 days after of receipt

1510 of the claim, pay the claim or notify a provider or designee if

1511 a claim is denied or contested. Notice of the health maintenance

1512 organization's action on the claim and payment of the claim is

1513 considered to be made on the date the notice or payment was

1514 received by the provider ~~mailed~~ or electronically transferred.

1515 (15) Notwithstanding paragraph (4)(a), effective November

1516 1, 2003, where a nonelectronic pharmacy claim is submitted to a

1517 pharmacy benefits manager acting on behalf of a health

1518 maintenance organization, the pharmacy benefits manager shall

1519 provide acknowledgment of receipt of the claim within 30 days

1520 after receipt of the claim to the provider or provide a provider

1521 within 30 days after receipt with electronic access to the

1522 status of a submitted claim.

1523 (16) Notwithstanding the 18-month ~~30-month~~ period provided

1524 in subsection (6) ~~(5),~~ all claims for overpayment submitted to a

1525 provider licensed under chapter 395, chapter 458, chapter 459,

1526 chapter 460, chapter 461, chapter 463, chapter 466, or chapter

1527 490 must be submitted to the provider within 12 months after the

1528 health maintenance organization's payment of the claim. An

1529 overpayment A claim to a provider licensed under chapter 395,

1530 458, chapter 459, chapter 460, chapter 461, chapter 463, chapter

1531 466, or chapter 490 is prohibited ~~for overpayment may not be~~

1532 ~~permitted~~ beyond 12 months after the health maintenance

1533 organization's payment of a claim, except that claims for

1534 overpayment may be sought beyond that time from providers

1535 convicted of fraud pursuant to s. 817.234.

1536 (17) Notwithstanding any other provision of this section,

1537 all claims for underpayment from a provider licensed under

1538 chapter 395, chapter 458, chapter 459, chapter 460, chapter 461,

1539 or chapter 466 must be submitted to the health maintenance

1540 organization within 12 months after the health maintenance

1541 organization's payment of the claim. A claim for underpayment by

1542 a provider licensed under chapter 395, 458, chapter 459, chapter

1543 460, chapter 461, or chapter 466 is prohibited ~~may not be~~

1544 ~~permitted~~ beyond 12 months after the health maintenance

1545 organization's payment of a claim.

1546 (18) Nothing in this section shall be interpreted to

1547 limit, restrict, or negatively impact any legal claim by a

1548 provider or health maintenance organization for breach of

1549 contract, statutory or regulatory violation, or a common-law

1550 cause of action, nor to shorten or otherwise negatively impact

1551 the statute of limitations timeframe for bringing any such legal

1552 claim.

1553 (19) A health insurer is prohibited from requesting

1554 information from a contracted or noncontracted provider which

1555 does not apply to the medical condition at issue for the

1556 purposes of adjudicating a clean claim.

1557 (20) A health maintenance organization is prohibited from

1558 requesting a contracted or noncontracted provider to resubmit

1559 claim information that the contracted or noncontracted provider

1560 can document it has already provided to the health maintenance

1561 organization or that is contained inside the electronic medical

1562 record to which the health maintenance organization has been

1563 provided access.

1564 (21) Notwithstanding any other provision of this section

1565 to the contrary, a health maintenance organization is prohibited

1566 from requiring any information from a provider before the

1567 provision of emergency health care services as a condition of

1568 payment of a claim, as a basis for denying, delaying,

1569 offsetting, withholding, or reducing payment of a claim, or in

1570 contesting whether the claim is a clean claim.

1571 (22) In an instance of a violation of this section, a

1572 provider shall have a private cause of action to proceed against

1573 the health maintenance organization in the applicable tribunal

1574 for the violation.

1575 Section 5. Paragraph (c) of subsection (2) of section

1576 395.1065, Florida Statutes, is amended to read:

1577 395.1065 Criminal and administrative penalties;

1578 moratorium.—

1579 (2)

1580 (c) The agency may impose an administrative fine for the

1581 violation of s. 641.3154 or, if sufficient claims due to a

1582 provider from a health maintenance organization do not exist to

1583 enable the take-back of an overpayment, as provided under s.

1584 641.3155(6) ~~s. 641.3155(5),~~ for the violation of s. 641.3155(5)

1585 ~~s. 641.3155(5).~~ The administrative fine for a violation cited in

1586 this paragraph shall be in the amounts specified in s.

1587 641.52(5), and the provisions of paragraph (a) do not apply.

1588 Section 6. This act shall take effect July 1, 2026.