No. HB 1097
Filed under Healthcare.
Health Insurer Accountability; Requires health plan to participate in filed claim dispute; provides penalties for failure to respond to claim; requires AHCA to notify certain entity within specified timeframe when health plan fails to pay provider; requires health plan to pay provider within specified timeframe after agency's order; provides credentialing requirements for managed care plan; requires each managed care plan to identify to agency & OIR any ownership interest of affiliation of any kind with certain entities; provides requirements for identification of such information; removes provision requiring results of certain audit reports to be dispositive; requires managed care contracts to include provider notifications regarding certain denials of coverage; prohibits insurer from denying certain claims; provides notification requirements & penalties.
Plain English Summary
AI-GENERATEDAn insurer or HMO can no longer deny a claim for care it already authorized unless it first notifies both the patient and the treating provider of the coverage change. Skipping that notice means the insurer must pay anyway.
A health plan that loses a claim dispute before the state agency must pay the provider within 35 days or face a penalty of up to $500 per day until it does.
Health plans must now take part in the state's claim dispute process at all; ignoring a dispute results in an automatic default against the plan.
Managed care plans must disclose to state regulators any ownership stake or affiliation, direct or indirect, with pharmacies, providers, or other companies tied to the care they cover.
AIAn insurer or HMO may not deny a claim for a health care service it already authorized unless it has notified both the insured and the treating provider of the change in coverage status or benefit limitation, in specified circumstances.
AIA health plan that loses a claim dispute before the agency must pay the provider the ordered amount within 35 days. Missing that deadline exposes the plan to a penalty of up to $500 per day until it pays.
AIA health plan must now take part in a filed claim dispute; if it does not respond as the process requires, the agency enters a default against the plan, the same as if it had lost the dispute outright.
AIEach managed care plan must tell the agency and the Office of Insurance Regulation about any ownership interest or affiliation it has with providers, provider groups, or companies handling pharmacy, diagnostics, care coordination, or related services.
AIEvery managed care contract with a provider in the Medicaid managed medical assistance program must include the provider-notification requirements for denials of coverage that the bill adds elsewhere.
AIOnce a provider has met credentialing and enrollment terms, its claims become payable retroactive to its credentialing application date, and a managed care plan may not make the provider appeal or resubmit a clean claim filed while credentialing was still pending.
AIA corrected achieved-savings-rebate audit report's results are no longer automatically final once submitted, removing a clause that had closed off further review of those results.