HB 1023 full text · Session Watch

1 A bill to be entitled

2 An act relating to insurance claims payments to health

3 care providers; amending s. 408.7057, F.S.; defining

4 the terms "claim dispute" and "denied prior

5 authorization request"; requiring the Agency for

6 Health Care Administration to establish a program to

7 assist health care providers and health plans in

8 resolving claims of denied prior authorization

9 requests; providing that the program is mandatory;

10 revising the list of claims that are not reviewed by

11 the program; prohibiting respondents from avoiding

12 default by refusing to participate in the review

13 process; requiring health plans to reimburse health

14 care providers' costs in bringing claims under certain

15 circumstances; requiring the agency to adopt rules;

16 amending ss. 627.6131 and 641.315, F.S.; prohibiting

17 contracts between health care providers and health

18 insurers and health maintenance organizations,

19 respectively, from specifying credit card payments to

20 providers as the only acceptable method for payments;

21 authorizing use of electronic funds transfers by

22 health insurers and health maintenance organizations,

23 respectively, for payments to providers under certain

24 circumstances; providing notification requirements;

25 prohibiting health insurers and health maintenance

26 organizations, respectively, from charging fees for

27 automated clearinghouse transfers as claims payments

28 to providers; providing an exception; providing

29 applicability; prohibiting health insurers and health

30 maintenance organizations, respectively, from denying

31 claims subsequently submitted by providers for

32 procedures that were included in prior authorizations;

33 providing exceptions; providing applicability;

34 defining the term "provider"; providing an effective

35 date.

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

39 Section 1. Section 408.7057, Florida Statutes, is amended to read:

41 408.7057 Statewide provider and health plan claim dispute

42 resolution program.—

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

44 (a) "Agency" means the Agency for Health Care

45 Administration.

46 (b) "Claim dispute" may include, but is not limited to, a

47 denied prior authorization request.

48 (c) "Denied prior authorization request" means a

49 determination by a health plan that a request submitted by a

50 provider for prior authorization of a health care service,

51 supply, or medication:

52 1. Has been wholly or partially denied;

53 2. Has not been acted upon within the time limits

54 established by law or contract; or

55 3. Has been approved subject to materially restrictive

56 conditions that prevent the service, supply, or medication from

57 being furnished as clinically indicated.

58 (d)(b) "Health plan" means a health maintenance

59 organization or a prepaid health clinic certified under chapter

60 641, a prepaid health plan authorized under s. 409.912, an

61 exclusive provider organization certified under s. 627.6472, or

62 a major medical expense health insurance policy, as defined in

63 s. 627.643(2)(e), offered by a group or an individual health

64 insurer licensed pursuant to chapter 624, including a preferred

65 provider organization under s. 627.6471.

66 (e)(c) "Resolution organization" means a qualified

67 independent third-party claim-dispute-resolution entity selected

68 by and contracted with the Agency for Health Care

69 Administration.

70 (2)(a) The agency shall establish a program to provide

71 assistance to contracted and noncontracted providers and health

72 plans for resolution of claim disputes that are not resolved by

73 the provider and the health plan. The agency shall contract with

74 a resolution organization to timely review and consider claim

75 disputes submitted by providers and health plans and recommend

76 to the agency an appropriate resolution of those disputes. The

77 agency shall establish by rule jurisdictional amounts and

78 methods of aggregation for claim disputes that may be considered

79 by the resolution organization.

80 (b) The dispute resolution program is a mandatory program,

81 and a provider or health plan may not opt out of the process.

82 The resolution organization shall review claim disputes filed by

83 contracted and noncontracted providers and health plans unless

84 the disputed claim:

85 1. Is related to interest payment;

86 2. Does not meet the jurisdictional amounts or the methods

87 of aggregation established by agency rule, as provided in

88 paragraph (a);

89 3. Is part of an internal grievance in a Medicare managed

90 care organization or a reconsideration appeal through the

91 Medicare appeals process;

92 4. Is related to a health plan that is not regulated by

93 the state;

94 5. Is part of a Medicaid fair hearing pursued under 42

95 C.F.R. ss. 431.220 et seq.;

96 6. Is the specific subject of an existing lawsuit filed

97 ~~basis for an action pending~~ in state or federal court before the

98 submission of the claim to the resolution organization; or

99 7. Is subject to a binding claim-dispute-resolution

100 process provided by contract entered into prior to October 1,

101 2000, between the provider and the managed care organization.

102 (c) Contracts entered into or renewed on or after October

103 1, 2000, may require exhaustion of an internal dispute-

104 resolution process as a prerequisite to the submission of a

105 claim by a provider or a health plan to the resolution

106 organization.

107 (d) A contracted or noncontracted provider or health plan

108 may not file a claim dispute with the resolution organization

109 more than 12 months after a final determination has been made on

110 a claim by a health plan or provider.

111 (e) The resolution organization shall require the health

112 plan or provider submitting the claim dispute to submit any

113 supporting documentation to the resolution organization within

114 15 days after receipt by the health plan or provider of a

115 request from the resolution organization for documentation in

116 support of the claim dispute. The resolution organization may

117 extend the time if appropriate. Failure to submit the supporting

118 documentation within such time period shall result in the

119 dismissal of the submitted claim dispute.

120 (f) The resolution organization shall require the

121 respondent in the claim dispute to submit all documentation in

122 support of its position within 15 days after receiving a request

123 from the resolution organization for supporting documentation.

124 The resolution organization may extend the time if appropriate.

125 Failure to submit the supporting documentation within such time

126 period shall result in a default against the health plan or

127 provider. The respondent may not avoid default by declining to

128 participate in the review process provided in this section. In

129 the event of such a default, the resolution organization shall

130 issue its written recommendation to the agency that a default be

131 entered against the defaulting entity. The written

132 recommendation shall include a recommendation to the agency that

133 the defaulting entity shall pay the entity submitting the claim

134 dispute the full amount of the claim dispute, plus all accrued

135 interest, and shall be considered a nonprevailing party for the

136 purposes of this section.

137 (g)1. If on an ongoing basis during the preceding 12

138 months, the agency has reason to believe that a pattern of

139 noncompliance with s. 627.6131 and s. 641.3155 exists on the

140 part of a particular health plan or provider, the agency shall

141 evaluate the information contained in these cases to determine

142 whether the information evidences a pattern and report its

143 findings, together with substantiating evidence, to the

144 appropriate licensure or certification entity for the health

145 plan or provider.

146 2. In addition, the agency shall prepare a report to the

147 Governor and the Legislature by February 1 of each year,

148 enumerating: claims dismissed; defaults issued; and failures to

149 comply with agency final orders issued under this section.

150 (h) Either the contracted or noncontracted provider or the

151 health plan may make an offer to settle the claim dispute when

152 it submits a request for a claim dispute and supporting

153 documentation. The offer to settle the claim dispute must state

154 its total amount, and the party to whom it is directed has 15

155 days to accept the offer once it is received. If the party

156 receiving the offer does not accept the offer and the final

157 order amount is more than 90 percent or less than 110 percent of

158 the offer amount, the party receiving the offer must pay the

159 final order amount to the offering party and is deemed a

160 nonprevailing party for purposes of this section. The amount of

161 an offer made by a contracted or noncontracted provider to

162 settle an alleged underpayment by the health plan must be

163 greater than 110 percent of the reimbursement amount the

164 provider received. The amount of an offer made by a health plan

165 to settle an alleged overpayment to the provider must be less

166 than 90 percent of the alleged overpayment amount by the health

167 plan. Both parties may agree to settle the disputed claim at any

168 time, for any amount, regardless of whether an offer to settle

169 was made or rejected.

170 (3) The agency shall adopt rules to establish a process to

171 be used by the resolution organization in considering claim

172 disputes submitted by a provider or health plan which must

173 include:

174 (a) That the resolution organization review and consider

175 all documentation submitted by both the health plan and the

176 provider;

177 (b) That the resolution organization's recommendation make

178 findings of fact;

179 (c) That either party may request that the resolution

180 organization conduct an evidentiary hearing in which both sides

181 can present evidence and examine witnesses, and for which the

182 cost of the hearing is equally shared by the parties;

183 (d) That the resolution organization may not communicate

184 ex parte with either the health plan or the provider during the

185 dispute resolution;

186 (e) That the resolution organization's written

187 recommendation, including findings of fact relating to the

188 calculation under s. 641.513(5) for the recommended amount due

189 for the disputed claim, include any evidence relied upon; and

190 (f) That the resolution organization issue a written

191 recommendation to the agency within 60 days after the requested

192 information is received by the resolution organization within

193 the timeframes specified by the resolution organization. In no

194 event shall the review time exceed 90 days following receipt of

195 the initial claim dispute submission by the resolution

196 organization.

197 (4) Within 30 days after receipt of the recommendation of

198 the resolution organization, the agency shall adopt the

199 recommendation as a final order. The final order is subject to

200 judicial review pursuant to s. 120.68.

201 (5) The agency shall notify within 7 days the appropriate

202 licensure or certification entity whenever there is a violation

203 of a final order issued by the agency pursuant to this section.

204 (6) The entity that does not prevail in the agency's order

205 must pay a review cost to the review organization, as determined

206 by agency rule. Such rule must provide for an apportionment of

207 the review fee in any case in which both parties prevail in

208 part. If the nonprevailing party fails to pay the ordered review

209 cost within 35 days after the agency's order, the nonpaying

210 party is subject to a penalty of not more than $500 per day

211 until the penalty is paid.

212 (7) If a claim dispute under this section involves a

213 denied prior authorization request and the health plan is

214 determined to be the nonprevailing party, the health plan shall

215 reimburse the provider for the provider's reasonable costs

216 incurred in bringing the claim, including any filing fees and

217 administrative costs assessed by the agency or its designee. The

218 agency shall adopt rules to specify allowable costs and

219 procedures for cost recovery under this subsection.

220 (8)(7) The agency may adopt rules to administer this

221 section.

222 Section 2. Subsections (20) and (21) of section 627.6131,

223 Florida Statutes, are amended to read:

224 627.6131 Payment of claims.—

225 (20)(a) A contract between a health insurer and a dentist

226 licensed under chapter 466 or a provider for the provision of

227 services to an insured may not specify credit card payment as

228 the only acceptable method for payments from the health insurer

229 to the dentist or provider.

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

231 payment to a dentist or provider through electronic funds

232 transfer, including, but not limited to, virtual credit card

233 payment, the health insurer shall notify the dentist or provider

234 as provided in this paragraph and obtain the dentist's or

235 provider's consent before employing the electronic funds

236 transfer. The dentist's or provider's consent described in this

237 paragraph applies to the dentist's or provider's entire

238 practice. For the purpose of this paragraph, the dentist's or

239 provider's consent, which may be given through e-mail, must bear

240 the signature of the dentist or provider. Such signature

241 includes an electronic or digital signature if the form of

242 signature is recognized as a valid signature under applicable

243 federal law or state contract law or an act that demonstrates

244 express consent, including, but not limited to, checking a box

245 indicating consent. The health insurer or the dentist or

246 provider may not require that a dentist's or provider's consent

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

248 basis. The notification provided by the health insurer to the

249 dentist or provider must include all of the following:

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

251 transfer.

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

253 health insurer, with clear instructions to the dentist or

254 provider on how to select an alternative payment method.

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

256 provider through automated clearinghouse transfer may not charge

257 a fee solely to transmit the payment to the dentist or provider

258 unless the dentist or provider has consented to the fee.

259 (d) This subsection applies to all contracts:

260 1. Between a health insurer and a dentist which are

261 delivered, issued, or renewed on or after January 1, 2025.

262 2. Between a health insurer and a provider which are

263 delivered, issued, or renewed on or after January 1, 2027.

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

265 subsection as provided by s. 624.307.

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

267 subsection.

268 (g) As used in this subsection, the term "provider" has

269 the same meaning as the term "health care provider" in s.

270 381.00321(1).

271 (21)(a) A health insurer may not deny any claim

272 subsequently submitted by a dentist licensed under chapter 466

273 or a provider for procedures specifically included in a prior

274 authorization unless at least one of the following circumstances

275 applies for each procedure denied:

276 1. Benefit limitations, such as annual maximums and

277 frequency limitations not applicable at the time of the prior

278 authorization, are reached subsequent to issuance of the prior

279 authorization.

280 2. The documentation provided by the person submitting the

281 claim fails to support the claim as originally authorized.

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

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

284 condition of the patient occurs such that the prior authorized

285 procedure would no longer be considered medically necessary,

286 based on the prevailing standard of care.

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

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

289 patient's condition occurs such that the prior authorized

290 procedure would at that time have required disapproval pursuant

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

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

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

294 following:

295 a. Another payor is responsible for payment.

296 b. The dentist or provider has already been paid for the

297 procedures identified in the claim.

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

299 authorization was based in whole or material part on erroneous

300 information provided to the health insurer by the dentist or

301 provider, patient, or other person not related to the insurer.

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

303 receive the procedure on the date of service.

304 e. The services were provided during the grace period

305 established under s. 627.608 or applicable federal regulations,

306 and the ~~dental~~ insurer notified the dentist or provider that the

307 patient was in the grace period when the dentist or provider

308 requested eligibility or enrollment verification from the ~~dental~~

309 insurer, if such request was made.

310 (b) This subsection applies to all contracts:

311 1. Between a health insurer and a dentist which are

312 delivered, issued, or renewed on or after January 1, 2025.

313 2. Between a health insurer and a provider which are

314 delivered, issued, or renewed on or after January 1, 2027.

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

316 subsection as provided by s. 624.307.

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

318 subsection.

319 (e) As used in this subsection, the term "provider" has

320 the same meaning as the term "health care provider" in s.

321 381.00321(1).

322 Section 3. Subsections (13) and (14) of section 641.315,

323 Florida Statutes, are amended to read:

324 641.315 Provider contracts.—

325 (13)(a) A contract between a health maintenance

326 organization and a dentist licensed under chapter 466 or a

327 provider for the provision of services to a subscriber of the

328 health maintenance organization may not specify credit card

329 payment as the only acceptable method for payments from the

330 health maintenance organization to the dentist or provider.

331 (b) When a health maintenance organization employs the

332 method of claims payment to a dentist or provider through

333 electronic funds transfer, including, but not limited to,

334 virtual credit card payment, the health maintenance organization

335 shall notify the dentist or provider as provided in this

336 paragraph and obtain the dentist's or provider's consent before

337 employing the electronic funds transfer. The dentist's or

338 provider's consent described in this paragraph applies to the

339 dentist's or provider's entire practice. For the purpose of this

340 paragraph, the dentist's or provider's consent, which may be

341 given through e-mail, must bear the signature of the dentist or

342 provider. Such signature includes an electronic or digital

343 signature if the form of signature is recognized as a valid

344 signature under applicable federal law or state contract law or

345 an act that demonstrates express consent, including, but not

346 limited to, checking a box indicating consent. The health

347 maintenance organization or the dentist or provider may not

348 require that a dentist's or provider's consent as described in

349 this paragraph be made on a patient-by-patient basis. The

350 notification provided by the health maintenance organization to

351 the dentist or provider must include all of the following:

352 1. The fees, if any, that are associated with the

353 electronic funds transfer.

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

355 health maintenance organization, with clear instructions to the

356 dentist or provider on how to select an alternative payment

357 method.

358 (c) A health maintenance organization that pays a claim to

359 a dentist or provider through automated clearinghouse ~~Clearing~~

360 ~~House~~ transfer may not charge a fee solely to transmit the

361 payment to the dentist or provider unless the dentist or

362 provider has consented to the fee.

363 (d) This subsection applies to all contracts:

364 1. Between a health maintenance organization and a dentist

365 which are delivered, issued, or renewed on or after January 1,

366 2025.

367 2. Between a health maintenance organization and a

368 provider which are delivered, issued, or renewed on or after

369 January 1, 2027.

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

371 subsection as provided by s. 624.307.

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

373 subsection.

374 (g) As used in this subsection, the term "provider" has

375 the same meaning as the term "health care provider" in s.

376 381.00321(1).

377 (14)(a) A health maintenance organization may not deny any

378 claim subsequently submitted by a dentist licensed under chapter

379 466 or a provider licensed for procedures specifically included

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

381 circumstances applies for each procedure denied:

382 1. Benefit limitations, such as annual maximums and

383 frequency limitations not applicable at the time of the prior

384 authorization, are reached subsequent to issuance of the prior

385 authorization.

386 2. The documentation provided by the person submitting the

387 claim fails to support the claim as originally authorized.

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

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

390 condition of the patient occurs such that the prior authorized

391 procedure would no longer be considered medically necessary,

392 based on the prevailing standard of care.

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

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

395 patient's condition occurs such that the prior authorized

396 procedure would at that time have required disapproval pursuant

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

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

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

400 following:

401 a. Another payor is responsible for payment.

402 b. The dentist or provider has already been paid for the

403 procedures identified in the claim.

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

405 authorization was based in whole or material part on erroneous

406 information provided to the health maintenance organization by

407 the dentist or provider, patient, or other person not related to

408 the organization.

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

410 receive the procedure on the date of service.

411 e. The services were provided during the grace period

412 established under s. 627.608 or applicable federal regulations,

413 and the health maintenance organization ~~dental insurer~~ notified

414 the dentist or provider that the patient was in the grace period

415 when the dentist or provider requested eligibility or enrollment

416 verification from the health maintenance organization ~~dental~~

417 ~~insurer,~~ if such request was made.

418 (b) This subsection applies to all contracts:

419 1. Between a health maintenance organization and a dentist

420 which are delivered, issued, or renewed on or after January 1,

421 2025.

422 2. Between a health maintenance organization and a

423 provider which are delivered, issued, or renewed on or after

424 January 1, 2027.

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

426 subsection as provided by s. 624.307.

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

428 subsection.

429 (e) As used in this subsection, the term "provider" has

430 the same meaning as the term "health care provider" in s.

431 381.00321(1).

432 Section 4. This act shall take effect July 1, 2026.