SB 1130 full text · Session Watch

Florida Senate - 2026 SB 1130 By Senator Massullo 11-00698A-26 20261130__

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.; defining

4 terms; prohibiting payment adjudicators from

5 downcoding health care services under certain

6 circumstances; providing exceptions; requiring payment

7 adjudicators to provide certain information to the

8 provider; prohibiting payment adjudicators from

9 downcoding a service under certain circumstances;

10 prohibiting payment adjudicators for downcoding orders

11 by a licensed nurse; specifying that payment

12 adjudicators are solely responsible for certain

13 violations of law; requiring payment adjudicators to

14 maintain downcoding policies on their websites;

15 specifying requirements for such policies; requiring

16 health insurers to ensure that their downcoding

17 policies are updated and to ensure compliance with

18 specified provisions on downcoding; authorizing

19 investigations and actions against noncompliance;

20 providing certain presumption in favor of physicians’

21 determinations regarding diagnoses of patients and

22 service orders; providing the calculation of interest

23 on health insurers’ nonpayment or underpayment due to

24 downcoding; providing a cause of action for health

25 care providers; amending s. 627.42392, F.S.; defining

26 terms; revising the definition of the term “health

27 insurer”; requiring certain utilization review

28 entities to only use a certain prior authorization

29 form; deleting provisions related to pharmacy benefits

30 managers’ or health insurers’ requirement to use a

31 specified prior authorization form; requiring

32 utilization review entities to establish and offer a

33 specified electronic prior authorization process;

34 specifying requirements for such process; specifying

35 that the provider is deemed to have supplied all

36 information necessary for prior authorization under

37 certain circumstances; specifying that additional

38 information is deemed unnecessary under certain

39 circumstances; prohibiting utilization review

40 entities’ prior authorization process from requiring

41 information that is not needed; requiring utilization

42 review entities to disclose all prior authorization

43 requirements and restrictions; requiring such

44 requirements and restrictions to be explained in a

45 specified manner; prohibiting utilization review

46 entities from implementing certain new requirements or

47 restrictions; providing exceptions; providing

48 reporting requirements; requiring the Office of

49 Insurance Regulation to publish on its website a

50 report based on such entities’ reports; providing

51 requirements for adverse determinations made by such

52 entities on health care providers’ claims; providing a

53 timeframe for such entities’ determination on claims;

54 prohibiting prior authorization requirements under

55 certain circumstances; prohibiting prior authorization

56 revocations, limits, conditions, and restrictions

57 under certain circumstances; providing exceptions;

58 providing a timeframe for the validity of prior

59 authorizations under certain circumstances; providing

60 construction; amending ss. 627.6131 and 641.3155,

61 F.S.; defining terms; revising the definition of the

62 term “claim”; revising requirements and timeframes for

63 responses from health insurers and health maintenance

64 organizations, respectively, to submitted claims;

65 revising the interest rate on overdue payments of

66 claims; authorizing health care providers to refuse to

67 participate in internal dispute resolution processes

68 under certain circumstances; prohibiting health

69 insurers and health maintenance organizations,

70 respectively, from retrospectively, rather than

71 retroactively, denying claims because of insured and

72 enrollee ineligibility beyond a specified timeframe;

73 revising such timeframe; revising applicability;

74 providing construction; prohibiting health insurers

75 and health maintenance organizations, respectively,

76 from requesting or requiring certain information from

77 health care providers under certain circumstances;

78 providing causes of action for health care providers

79 under certain circumstances; amending s. 395.1065,

80 F.S.; conforming cross-references; providing an

81 effective date.

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

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

86 to read:

87 627.4193 Restrictions on health insurance reimbursement

88 downcoding.—

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

90 (a) “Downcode” or “downcoding” means the alteration by a

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

92 the alteration, addition, or deletion by a payment adjudicator

93 of a modifier, when the changed code or modifier is associated

94 with a lower payment amount than the service code or modifier

95 billed by the provider or facility.

96 (b) “Health insurer” means any entity that offers health

97 insurance coverage, whether through a fully insured plan or

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

99 1. An authorized health insurer offering health insurance

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

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

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

103 2. A health insurer that is subject to any provision of

104 this chapter, as well as any entity that offers a self-insurance

105 plan or a group self-insurance plan.

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

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

108 641.19.

109 (c) “Medical record” means the comprehensive collection of

110 documentation, including clinical notes, diagnostic reports, and

111 other relevant information, which supports the health care

112 services provided.

113 (d) “Participation agreement” means a written contract or

114 agreement between a health insurer and a provider which outlines

115 the terms and conditions of participation, reimbursement rates,

116 and other relevant details.

117 (e) “Payment adjudicator” means a health insurer or any

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

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

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

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

122 for hospital services, outpatient services, medical services,

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

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

125 under a policy, plan, or contract.

126 (f) “Provider” means any health care professional,

127 facility, or entity that submits claims for reimbursement for

128 covered health care services.

129 (2) Payment adjudicators are prohibited from downcoding a

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

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

132 network with the applicable health insurer, unless such

133 downcoding is otherwise expressly permitted under the

134 participation agreement between the health insurer and the

135 provider.

136 (3) If downcoding is expressly permitted under the

137 participation agreement, the payment adjudicator must provide

138 the following information to the provider before making its

139 initial payment or notice of denial of payment:

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

141 modifier billed by the provider or facility will be downcoded.

142 (b) An explanation detailing the reasons for downcoding the

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

144 service codes or modifiers that were altered, added, or deleted,

145 if applicable.

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

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

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

149 downcoding of the applicable service code or modifier by filing

150 a contestation with the payment adjudicator with respect to the

151 downcoding within 15 days after receipt of the notice of

152 downcoding.

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

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

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

156 payment adjudicator to the fullest extent permissible under law.

157 (4) Even if the participation agreement expressly permits

158 downcoding, a payment adjudicator is prohibited from downcoding

159 a service without first conducting a review of the associated

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

161 (5) A payment adjudicator is prohibited from downcoding for

162 orders by a licensed nurse.

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

164 payment adjudicator that proceeds to downcode a service code or

165 modifier, regardless of whether such downcoding is contested by

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

167 associated with such downcoding.

168 (7) Payment adjudicators are required to maintain clear and

169 accessible downcoding policies on their official website. These

170 policies must include:

171 (a) An overview of the circumstances under which downcoding

172 may occur.

173 (b) The process and criteria used for conducting reviews of

174 downcoded claims, including the role of medical record review.

175 (c) Information about the internal mechanisms for ensuring

176 consistency and accuracy in downcoding practices.

177 (d) Information regarding the processes for contesting with

178 the payment adjudicator the downcoding of a service code, which

179 processes must offer appeal rights for the provider and the

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

181 downcoding.

182 (8) Health insurers shall ensure that their downcoding

183 policies are updated as needed to reflect any changes in

184 regulations, industry standards, or internal procedures.

185 (9) Health insurers shall ensure compliance with this

186 section and shall develop internal procedures to implement and

187 adhere to the requirements outlined in this section.

188 (10) Regulatory authorities, including, but not limited to,

189 the Office of Insurance Regulation, may investigate and take

190 appropriate actions in cases of noncompliance with this section.

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

192 licensed physician, there is a presumption that the physician’s

193 determination regarding the diagnosis of the patient and any

194 service order by the physician is correct and sufficient, absent

195 a coding error which the health insurer must first verify with

196 the physician before downcoding for such error.

197 (12) If an applicable court, arbitration tribunal, or other

198 binding legal process determines that a claim was subject to an

199 inappropriate or impermissible downcoding, whether in breach of

200 contract, statute, common law, or otherwise, such that

201 nonpayment or underpayment of the original claim has occurred,

202 then in accordance with s. 627.6131, interest must be calculated

203 on the full total amount that should have been paid on the claim

204 as of the applicable time period for payment specified in s.

205 627.6131.

206 (13) For a violation of this section, a provider shall have

207 a private cause of action to proceed against the health insurer

208 or payment adjudicator in the applicable tribunal for the

209 violation.

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

211 to read:

212 627.42392 Prior authorization.—

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

214 (a) “Adverse determination” means a decision by a health

215 insurer or utilization review entity that the health care

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

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

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

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

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

221 (b) “Electronic prior authorization process” does not

222 include transmissions through a facsimile machine.

223 (c) “Emergency health care service” means medical

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

225 the extent permitted by applicable law, by other appropriate

226 personnel under the supervision of a physician, to determine

227 whether an emergency medical condition exists and, if it does,

228 the care, treatment, or surgery by a physician necessary to

229 relieve or eliminate the emergency medical condition, within the

230 service capability of the facility.

231 (d) “Emergency medical condition” means a medical condition

232 manifesting itself by acute symptoms of sufficient severity,

233 including severe pain, such that a prudent layperson who

234 possesses an average knowledge of health and medicine could

235 reasonably expect the absence of immediate medical attention to

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

237 (e) “Health insurer” means any entity that offers health

238 insurance coverage, whether through a fully insured plan or

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

240 1. An authorized health insurer offering health insurance

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

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

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

244 2. A health insurer that is subject to any provision of

245 this chapter, as well as any entity that offers a self-insurance

246 plan or a group self-insurance plan.

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

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

249 641.19.

250 (f) “Prior authorization” means the process by which

251 utilization review entities determine the medical necessity or

252 medical appropriateness of otherwise covered health care

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

254 term also includes any requirement by a health insurer or

255 utilization review entity that an enrollee or a health care

256 provider notify the health insurer or utilization review entity

257 before the provision of a health care service.

258 (g) “Urgent health care service” means a health care

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

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

261 with knowledge of the patient’s medical condition:

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

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

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

265 adequately managed without the care, treatment, or prescription

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

267 (h) “Utilization review activity” means any activity

268 prospective to, concurrent with, or retrospective to the

269 provision of a nonemergency health care service, to determine

270 whether payment must be made in full or is subject to an adverse

271 determination. Utilization review activity is prohibited:

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

273 with a health care provider;

274 2. For an emergency health care service; or

275 3. For a service provided to a patient experiencing an

276 emergency medical condition.

277 (i) “Utilization review entity” means an entity permitted

278 under the applicable agreement with a health care provider or

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

280 agreement to perform utilization review activities or upon whose

281 behalf utilization review activities are performed, including,

282 as applicable:

283 1. An authorized health insurer offering health insurance

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

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

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

287 2. A health insurer that is subject to any provision of

288 this chapter, as well as any entity that offers a self-insurance

289 plan or a group self-insurance plan.

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

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

292 641.19.

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

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

295 provide, or administers payment for hospital services,

296 outpatient services, medical services, prescription drugs, or

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

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

299 contract, or fund ~~“health insurer” means an authorized insurer~~

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

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

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

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

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

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

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

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

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

309 for use by its contracted providers may ~~, shall~~ only use the

310 prior authorization form that has been approved by the Financial

311 Services Commission for granting a prior authorization for a

312 medical procedure, course of treatment, or prescription drug

313 benefit. Such form must be no longer than ~~may not exceed~~ two

314 pages in length, excluding any instructions or guiding

315 documentation, and must include all clinical documentation

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

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

318 sufficient patient information to identify the member, date of

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

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

321 treatment, or prescription drug benefit being requested,

322 including the medical reason therefor, and all services tried

323 and failed; ~~(4)~~ any laboratory documentation required; and ~~(5)~~

324 an attestation that all information provided is true and

325 accurate.

326 (3) The Financial Services Commission , in consultation with

327 the Agency for Health Care Administration , shall adopt by rule

328 guidelines for all prior authorization forms which ensure the

329 general uniformity of such forms.

330 (4) A utilization review entity shall establish and offer a

331 secure, interactive online electronic prior authorization

332 process to accept electronic prior authorization requests. The

333 electronic prior authorization process must allow a person

334 seeking a prior authorization the ability to upload

335 documentation if such documentation is required by the

336 utilization review entity to adjudicate the prior authorization

337 request. Once a provider grants a health insurer access to a

338 patient’s electronic medical record, the provider is deemed to

339 have supplied all information necessary for prior authorization

340 of the health care service, including, without limitation, all

341 information that is reasonably required by the health insurer,

342 other than for an emergency health care service or for a service

343 provided to a patient who is experiencing an emergency medical

344 condition, in advance of the provision of service, and the

345 health insurer asserts is missing as of the date of such

346 service. Additional information or documentation, regardless of

347 whether the utilization review entity requests any additional

348 information, is deemed unnecessary, and deemed not required, for

349 prior authorization of the health care service, and any request

350 for additional information or any position of the utilization

351 review entity or any third party acting on behalf of the

352 utilization review entity regarding any lack of information from

353 the provider is prohibited from being used to deny, pend, or

354 delay prior authorization of the health care service.

355 (5) ~~(4)~~ Electronic prior authorization approvals do not

356 preclude benefit verification or medical review by the health

357 insurer under either the medical or pharmacy benefits.

358 (6) A utilization review entity’s prior authorization

359 process is prohibited from requiring information that is not

360 needed to make a determination or facilitate a determination of

361 medical necessity of the requested medical procedure, course of

362 treatment, or prescription drug benefit.

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

364 prior authorization requirements and restrictions, including any

365 written clinical criteria, in a publicly accessible manner on

366 its website. These requirements and restrictions must be

367 explained in detail and in clear and ordinary terms.

368 (8) A utilization review entity is prohibited from

369 implementing any new requirements or restrictions and from

370 making changes to existing requirements or restrictions on

371 obtaining prior authorization unless:

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

373 accessible website for at least 60 days before they are

374 implemented;

375 (b) Policyholders and health care providers affected by the

376 new requirements and restrictions or changes to the requirements

377 and restrictions are provided with a written notice of the

378 changes at least 60 days before they are implemented, with such

379 notice being delivered electronically or by other means as

380 agreed to by the policyholder or the health care provider; and

381 (c) All applicable amendments to a provider’s agreement

382 with the applicable health insurer or utilization review entity

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

384 writing before such implementation.

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

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

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

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

389 authorization.

390 2. The percentage of standard prior authorization requests

391 approved by the utilization review entity, aggregated by item or

392 service.

393 3. The percentage of standard prior authorization requests

394 denied by the utilization review entity, aggregated by item or

395 service.

396 4. The percentage of standard prior authorization requests

397 approved by the utilization review entity after appeal,

398 aggregated by item or service.

399 5. The percentage of prior authorizations when the

400 timeframe for review was extended and request approved, by item

401 or service.

402 6. The percentage of expedited prior authorization requests

403 approved by the utilization review entity, by item or service.

404 7. The percentage of expedited prior authorization requests

405 denied by the utilization review entity, by item or service.

406 8. The percentage of expedited prior authorization requests

407 approved by the utilization review entity after appeal, by item

408 or service.

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

410 request for prior authorization and the utilization review

411 entity’s decision for standard prior authorizations, by item or

412 service.

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

414 request for prior authorization and the utilization review

415 entity’s decision for expedited prior authorizations, by item or

416 service.

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

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

419 information in paragraph (a) submitted by utilization review

420 entities.

421 (10) Utilization review entities shall ensure that all

422 adverse determinations are made by a physician licensed under

423 chapter 458 or chapter 459. The physician:

424 (a) Must possess a current and valid nonrestricted license

425 to practice medicine in this state;

426 (b) Must be of the same specialty as the physician who

427 typically manages the medical condition or disease or provides

428 the health care service involved in the request;

429 (c) Must have at least 5 years of experience treating

430 patients with the medical condition or disease for which the

431 health care service is being requested; and

432 (d) May not have any direct or indirect financial

433 arrangement with the utilization review entity that rewards or

434 incentivizes, financially or otherwise, such physician in any

435 way relating to adverse determinations.

436 (11) Notice of an adverse determination must be provided by

437 e-mail to the health care provider that initiated the prior

438 authorization and to the patient. Notice required under this

439 subsection must include:

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

441 of the physician responsible for making the adverse

442 determination.

443 (b) Any written clinical criteria and any internal rule,

444 guideline, or protocol on which the utilization review entity

445 relied when making the adverse determination and the reasons

446 those provisions apply to the patient’s specific medical

447 circumstance.

448 (c) Information for the patient and the patient’s health

449 care provider which describes the procedure through which the

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

451 developed by personnel performing the review that led to the

452 adverse determination.

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

454 patient’s health care provider the manner in which to appeal the

455 adverse determination.

456 (12) If a utilization review entity requires prior

457 authorization of a nonurgent health care service, the

458 utilization review entity must grant a prior authorization or

459 make an adverse determination and notify the patient and the

460 patient’s health care provider of the decision within 72 hours

461 after obtaining all necessary information to grant the prior

462 authorization or make the adverse determination. For purposes of

463 this subsection, the term “necessary information” includes the

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

465 opinion that may be required.

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

467 prior authorization or make an expedited adverse determination

468 concerning an urgent health care service and notify the patient

469 and the patient’s health care provider of such expedited prior

470 authorization or adverse determination no later than 24 hours

471 after receiving all information needed to complete the review of

472 the requested urgent health care service.

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

474 requiring prior authorization for:

475 1. Prehospital transportation;

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

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

478 an emergency medical condition.

479 (b) A utilization review entity is prohibited from

480 conducting utilization review activity, and from making any

481 adverse determinations, to the extent restricted or prohibited

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

483 review entity is prohibited from performing any utilization

484 review activity, and from making any adverse determinations,

485 with respect to:

486 1. An emergency health care service; or

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

488 emergency medical condition.

489 (15) A utilization review entity is prohibited from

490 requiring prior authorization, and from making any adverse

491 determinations, for the provision of medications for opioid use

492 disorder. For purposes of this subsection, the term “medications

493 for opioid use disorder” means the use of medications, commonly

494 prescribed in combination with counseling and behavioral

495 therapies, to provide a comprehensive approach to the treatment

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

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

498 buprenorphine, alone or in combination with naloxone, and

499 extended-release injectable naltrexone. Types of behavioral

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

501 group counseling, family behavior therapy, motivational

502 incentives, and other modalities.

503 (16) A utilization review entity is prohibited from

504 revoking, limiting, conditioning, or restricting a prior

505 authorization if care is provided within 45 business days after

506 the date the health care provider receives the prior

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

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

509 prepayment review or prepayment audit before such payment, at

510 the contracted payment rate for a health care service provided

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

512 (a) The health care provider knowingly and materially

513 misrepresented the health care service in the prior

514 authorization request with the specific intent to deceive and

515 obtain an unlawful payment from the utilization review entity;

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

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

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

519 service was provided, and the utilization review entity notified

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

521 health care service was provided;

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

523 (d) The patient was no longer enrolled under the applicable

524 health plan and, on that basis, was not eligible for health care

525 coverage from the applicable health insurer or self-insured plan

526 on the day the care was provided, and the utilization review

527 entity notified the health care provider in writing of these

528 facts before the health care service was provided.

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

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

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

532 must remain valid for the length of the treatment, and the

533 utilization review entity is prohibited from requiring the

534 patient to obtain a prior authorization again for the health

535 care service.

536 (18) A utilization review entity is prohibited from

537 imposing an additional prior authorization requirement with

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

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

540 the procedure or item is furnished during the perioperative

541 period of another procedure for which prior authorization was

542 granted by the health insurer.

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

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

545 coverage or approval criteria is prohibited from adversely

546 affecting an enrollee who received prior authorization before

547 the effective date of the change for the remainder of the

548 enrollee’s plan year.

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

550 prior authorization it has granted to an enrollee when the

551 enrollee changes products under the same health insurer.

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

553 with the deadlines and other requirements specified in this

554 section will result in any health care services subject to

555 review being automatically deemed authorized by the utilization

556 review entity.

557 (22) Except as otherwise provided in paragraphs (16)(a)

558 (d), prior authorization constitutes a conclusive determination

559 of the medical necessity of the authorized health care service

560 and an irrevocable obligation to pay for such authorized health

561 care service.

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

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

564 utilization review activity or prior authorization.

565 (b) Nothing in this section may be construed to:

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

567 adverse determinations under an agreement with a health care

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

569 adverse determinations for emergency health care services.

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

571 authorizations under an agreement between a provider and a

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

573 provider’s rights to contest, reject, or oppose any prior

574 authorization activities.

575 (24) For a violation of this section, a provider shall have

576 a private cause of action to proceed against the health insurer

577 or utilization review entity in the applicable tribunal for the

578 violation.

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

580 to read:

581 627.6131 Prompt payment of claims.—

582 (1) The contract must ~~shall~~ include the following

583 provision: “Time of Payment of Claims: After receiving written

584 proof of loss, the health insurer shall ~~will~~ pay monthly all

585 claims. Claims ~~benefits then due for ...(type of benefit)....~~

586 ~~Benefits~~ for any other loss covered by this policy shall ~~will~~ be

587 paid as soon as the health insurer receives proper written

588 proof.”

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

590 (a) “Claim” for a noninstitutional provider means a paper

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

592 instrument submitted to the health insurer’s designated location

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

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

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

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

597 chapter 490 or any appropriate billing instrument as designated

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

599 noninstitutional provider. For institutional providers, “claim”

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

601 electronic billing instrument submitted to the health insurer’s

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

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

604 as mandatory by the National Uniform Billing Committee.

605 (b) “Clean claim” means a completed form, or completed

606 electronic billing instrument, containing all information

607 required under the applicable form or electronic billing

608 instrument, as well as information reasonably required by the

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

610 defined in s. 395.002, in advance of the provision of service by

611 the health insurer to substantiate the claim.

612 (c) “Electronic medical record” means the digital record of

613 a patient’s information that may be accessed through electronic

614 means, via portal or other method of electronic access, which

615 may include information regarding the patient’s medical history,

616 medical condition, medical treatment, laboratory results,

617 diagnostic reports, and clinical notes.

618 (d) “Emergency health care services” has the same meaning

619 as “emergency services and care” as defined in s. 395.002.

620 (e) “Health insurer” means any entity that offers health

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

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

623 1. An authorized health insurer offering health insurance

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

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

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

627 2. A health insurer that is subject to any provision of

628 this chapter, as well as any entity that offers a self-insurance

629 plan or a group self-insurance plan.

630 (f) “Insured ineligibility” means that the insured was no

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

632 applicable service.

633 (g) “Overpayment” means payment made upon a claim that is:

634 1. Billed in error;

635 2. A duplicate claim; or

636 3. Billed for a service rendered to a patient despite

637 insured ineligibility.

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

640 duplicate bill, or insured ineligibility.

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

642 electronic or nonelectronic:

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

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

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

646 by the provider at its designated location.

647 (b) As to providers’ claims for payment, must be mailed or

648 electronically transferred to the primary health insurer within

649 6 months after the following have occurred:

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

651 for outpatient services; and

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

653 and address of the patient’s health insurer.

655 All providers’ claims for payment, whether electronic or

656 nonelectronic, must be mailed or electronically transferred to

657 the secondary health insurer within 45 90 days after final

658 determination by the primary health insurer. A provider’s claim

659 is considered submitted on the date it is electronically

660 transferred or mailed.

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

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

663 otherwise lost.

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

665 insurer shall:

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

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

668 electronic source submitting the claim an electronic

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

670 statement indicating the health insurer’s position as to whether

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

672 required under the applicable electronic billing instrument, as

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

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

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

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

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

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

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

680 contested. Notice of the health insurer’s action on the claim

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

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

683 electronically transferred.

684 (c)1. Notification of the health insurer’s determination of

685 a contested claim must be accompanied by an itemized list of any

686 ~~additional~~ information that is required under the applicable

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

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

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

690 service to substantiate the claim, and the health insurer

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

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

693 ~~the claim~~ .

694 2. A provider must submit the additional information or

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

696 days after receipt of the notification of contestation unless,

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

698 insurer of the provider’s position that a clean claim has been

699 submitted . Additional information is considered submitted on the

700 date it is electronically transferred or mailed. The health

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

702 documents.

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

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

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

706 insurer and the provider.

707 (e) A claim contested by the health insurer must be paid or

708 denied within 30 90 days after receipt of the additional

709 information requested ~~claim~~ . Failure to pay or deny a claim

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

711 whether contested by the health insurer, creates an

712 uncontestable obligation to pay the claim as submitted by the

713 provider .

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

715 insurer shall:

716 (a) Within 15 days following receipt of the claim ~~Effective~~

717 ~~November 1, 2003~~ , provide to the provider or its designee:

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

719 by a statement indicating the health insurer’s position as to

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

721 information that is required under the applicable paper billing

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

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

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

725 substantiate the claim, and the health insurer asserts is

726 missing as of the date of service; or

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

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

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

730 status must indicate the health insurer’s position as to whether

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

732 in subparagraph 1 .

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

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

735 contested. Notice of the health insurer’s action on the claim

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

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

738 electronically transferred.

739 (c)1. Notification of the health insurer’s determination of

740 a contested claim must be accompanied by an itemized list of any

741 ~~additional~~ information that is required under the applicable

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

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

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

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

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

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

748 ~~the claim~~ .

749 2. A provider must submit the additional information or

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

751 days after receipt of the notification of contestation unless,

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

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

754 Additional information is considered submitted on the date it is

755 electronically transferred or mailed. The health insurer is

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

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

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

759 must ~~shall~~ be used to the greatest extent possible by the health

760 insurer and the provider.

761 (e) A claim contested by the health insurer must be paid or

762 denied within 30 ~~120~~ days after receipt of the additional

763 information requested ~~claim~~ . Failure to pay or deny a claim

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

765 whether contested by the health insurer, creates an

766 uncontestable obligation to pay the claim as submitted by the

767 provider .

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

769 electronically or nonelectronically, and notwithstanding any

770 other provision of this section:

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

772 patient’s electronic medical record, the provider is deemed to

773 have supplied all information necessary to pay the claim,

774 including, without limitation, all information that is required

775 under the applicable billing instrument and that was reasonably

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

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

778 substantiate the claim. Additional information or documentation,

779 regardless of whether the health insurer requests any additional

780 information, is deemed unnecessary, and deemed not required for

781 payment of the claim, and any request for additional

782 information, and any position of the health insurer or any third

783 party acting on behalf of the health insurer regarding any lack

784 of information from the provider, is prohibited from being used

785 to deny, reduce, offset, withhold, pend, or delay payment of the

786 claim.

787 (b) If notice of access to the electronic medical record

788 has been provided to the health insurer, the claim must be paid

789 or denied within 30 days of such notice to the health insurer.

790 Failure to pay or deny a claim for which the health insurer has

791 been provided notice of access to the electronic medical record

792 within 75 days after receipt of such notice creates an

793 uncontestable obligation to pay the claim as submitted by the

794 provider.

795 (7) ~~(6)~~ If a health insurer determines that it has made an

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

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

798 overpayment to the provider’s designated location. A health

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

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

801 electronic statement specifying the basis for the retrospective

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

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

804 to which the health insurer alleges overpayment ~~claim~~ , and the

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

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

807 as provided in subparagraph (a)3., there may be no denial,

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

809 other negative impact, regardless of whether by the health

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

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

812 basis of the overpayment allegation.

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

814 retrospective ~~retroactive~~ review or retrospective audit of

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

816 health insurer must ~~shall~~ adhere to the following procedures:

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

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

819 health insurer’s payment of the claim. A provider must pay,

820 deny, or contest the health insurer’s ~~claim for~~ overpayment

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

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

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

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

825 after receipt creates an uncontestable obligation to pay the

826 overpayment claim.

827 2. A provider that denies or contests a health insurer’s

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

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

830 within 40 35 days after the provider receives the overpayment

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

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

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

834 contested portion of the overpayment claim and the specific

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

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

837 the health insurer submits additional information, the health

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

839 or electronically transfer the information to the provider. The

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

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

842 the provider regarding denial or contestation of the overpayment

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

844 electronically transferred by the provider.

845 3. The health insurer is prohibited from denying, reducing,

846 offsetting, withholding, pending, or delaying ~~may not reduce~~

847 payment to the provider for other services unless the provider

848 agrees to the denial, reduction , offset, withholding, pending,

849 or delay of payment in writing or fails to respond to the health

850 insurer’s overpayment claim as required by this paragraph.

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

852 the date the payment was mailed or electronically transferred.

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

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

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

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

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

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

859 insurer’s payment of a claim, except that overpayment claims ~~for~~

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

861 convicted of fraud pursuant to s. 817.234.

862 (8) ~~(7)~~ Payment of a claim is considered made on the date

863 the payment was mailed or electronically transferred. An overdue

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

865 year , to be calculated on the full total amount that should have

866 been paid on the claim within the applicable time period

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

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

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

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

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

872 basis, the 15 percent per year interest must be calculated on

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

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

875 an applicable court, arbitration tribunal, or other binding

876 legal process determines that a claim was subject to an

877 inappropriate or impermissible denial or partial denial, whether

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

879 interest must be calculated on the full total amount that should

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

881 for payment specified in this section, and the act of denial or

882 partial denial is deemed not to have in any way tolled the time

883 period for such payment . Interest on the full total amount that

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

885 period specified in this section ~~an overdue payment for a claim~~

886 ~~or for any portion of a claim~~ begins to accrue when the claim

887 should have been paid ~~, denied, or contested~~ . The interest must

888 be paid along with, and in addition to, the payment for the

889 satisfaction of the full total amount of the claim, as

890 determined by an applicable court, arbitration tribunal, or

891 other binding legal process ~~is payable with the payment of the~~

892 ~~claim~~ .

893 (9) ~~(8)~~ For all contracts entered into or renewed on or

894 after October 1, 2002, a health insurer’s internal dispute

895 resolution process related to a denied claim not under active

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

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

898 provider’s request for review or appeal. Notwithstanding any

899 provision of this section, when the provider and health insurer

900 disagree as to interpretation of contractual or statutory

901 language, the provider is not required to participate in the

902 health insurer’s internal dispute resolution process.

903 (10) ~~(9)~~ A provider or any representative of a provider,

904 regardless of whether the provider is under contract with the

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

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

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

908 credit agency an insured for payment of covered services for

909 which the health insurer contested or denied the provider’s

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

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

912 payment of the services or internal dispute resolution process

913 to determine whether the health insurer is liable for the

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

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

916 completion of the health insurer’s internal dispute resolution

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

918 prohibit the collection by the provider of copayments,

919 coinsurance, or deductible amounts due the provider.

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

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

922 (11) A health insurer is prohibited from retrospectively

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

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

925 of the claim.

926 (12) A health insurer must ~~shall~~ pay a contracted primary

927 care or admitting physician, pursuant to such physician’s

928 contract, for providing inpatient services in a contracted

929 hospital to an insured if such services are determined by such

930 physician ~~the health insurer~~ to be medically necessary and ,

931 regardless of the health plan’s determination of medical

932 necessity, are otherwise covered services under the health

933 insurer’s contract with the contract holder.

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

935 insurer shall investigate any claim of improper billing of the

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

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

938 received . The health insurer shall determine whether if the

939 insured actually received the applicable service ~~was properly~~

940 ~~billed for only those procedures and services that the insured~~

941 ~~actually received~~ . If the health insurer determines that the

942 insured did not actually receive the applicable service ~~has been~~

943 ~~improperly billed~~ , the health insurer must ~~shall~~ notify the

944 insured and the provider of its findings and must ~~shall~~ reduce

945 the amount of payment to the provider by the amount for the

946 service that was not actually received ~~determined to be~~

947 ~~improperly billed~~ . ~~If a reduction is made due to such~~

948 ~~notification by the insured, the insurer shall pay to the~~

949 ~~insured 20 percent of the amount of the reduction up to $500~~ .

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

951 for health insurer’s claims payment violations of paragraphs

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

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

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

955 fine may ~~shall~~ be assessed for the noted claims violations for

956 the audit period. The error ratio is ~~shall be~~ determined by

957 dividing the number of claims with violations found on a

958 statistically valid sample of claims for the audit period by the

959 total number of claims in the sample. If the error ratio exceeds

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

961 according to s. 624.4211 for those claims payment violations

962 which exceed the error ratio. Notwithstanding the provisions of

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

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

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

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

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

968 determines were due to circumstances beyond the health insurer’s

969 control.

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

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

972 offered by a group or an individual health insurer licensed

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

974 policy under s. 627.6471 and an exclusive provider organization

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

976 that only provides direct payments to dentists for enumerated

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

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

979 offered or administered by a health insurer .

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

981 pharmacy claim is submitted to a pharmacy benefits manager

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

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

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

985 contested. Notice of the health insurer’s action on the claim

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

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

988 electronically transferred.

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

990 1, 2003, where a nonelectronic pharmacy claim is submitted to a

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

992 the pharmacy benefits manager shall provide acknowledgment of

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

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

995 receipt with electronic access to the status of a submitted

996 claim.

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

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

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

1000 chapter 459, chapter 460, chapter 461, chapter 463, chapter 466,

1001 or chapter 490 must be submitted to the provider within 12

1002 months after the health insurer’s payment of the claim. An

1003 overpayment A claim to a provider licensed under chapter 395,

1004 chapter 458, chapter 459, chapter 460, chapter 461, chapter 463,

1005 chapter 466, or chapter 490 is prohibited ~~for overpayment may~~

1006 ~~not be permitted~~ beyond 12 months after the health insurer’s

1007 payment of a claim, except that overpayment claims ~~for~~

1008 ~~overpayment~~ may be sought beyond that time from providers

1009 convicted of fraud pursuant to s. 817.234.

1010 (19) Notwithstanding any other provision of this section,

1011 all claims for underpayment from a provider licensed under

1012 chapter 395, chapter 458, chapter 459, chapter 460, chapter 461,

1013 or chapter 466 must be submitted to the health insurer within 12

1014 months after the health insurer’s payment of the claim. A claim

1015 for underpayment by a provider licensed under chapter 395,

1016 chapter 458, chapter 459, chapter 460, chapter 461, or chapter

1017 466 is prohibited ~~may not be permitted~~ beyond 12 months after

1018 the health insurer’s payment of a claim.

1019 (20) Nothing in this section shall be interpreted to limit,

1020 restrict, or negatively impact any legal claim by a provider or

1021 health insurer for breach of contract, statutory or regulatory

1022 violation, or a common-law cause of action, nor to shorten or

1023 otherwise negatively impact the statute of limitations timeframe

1024 for bringing any such legal claim.

1025 (21) A health insurer is prohibited from requesting

1026 information from a contracted or noncontracted provider which

1027 does not apply to the medical condition at issue for the

1028 purposes of adjudicating a clean claim.

1029 (22) A health insurer is prohibited from requesting a

1030 contracted or noncontracted provider to resubmit claim

1031 information that the contracted or noncontracted provider can

1032 document it has already provided to the health insurer or that

1033 is contained inside the electronic medical record to which the

1034 health insurer has been provided access.

1035 (23) Notwithstanding any other provision of this section, a

1036 health insurer is prohibited from requiring any information from

1037 a provider before the provision of emergency health care

1038 services as a condition of payment of a claim, as a basis for

1039 denying, delaying, offsetting, withholding, or reducing payment

1040 of a claim, or in contesting whether the claim is a clean claim.

1041 (24) For a violation of this section, a provider shall have

1042 a private cause of action to proceed against the health insurer

1043 in the applicable tribunal for the violation.

1044 (25) ~~(20)~~ (a) A contract between a health insurer and a

1045 dentist licensed under chapter 466 for the provision of services

1046 to an insured is prohibited from specifying ~~may not specify~~

1047 credit card payment as the only acceptable method for payments

1048 from the health insurer to the dentist.

1049 (b) When a health insurer employs the method of claims

1050 payment to a dentist through electronic funds transfer,

1051 including, but not limited to, virtual credit card payment, the

1052 health insurer shall notify the dentist as provided in this

1053 paragraph and obtain the dentist’s consent before employing the

1054 electronic funds transfer. The dentist’s consent described in

1055 this paragraph applies to the dentist’s entire practice. For the

1056 purpose of this paragraph, the dentist’s consent, which may be

1057 given through e-mail, must bear the signature of the dentist.

1058 Such signature includes an electronic or digital signature if

1059 the form of signature is recognized as a valid signature under

1060 applicable federal law or state contract law or an act that

1061 demonstrates express consent, including, but not limited to,

1062 checking a box indicating consent. The health insurer or dentist

1063 is prohibited from requiring ~~may not require~~ that a dentist’s

1064 consent as described in this paragraph be made on a patient-by

1065 patient basis. The notification provided by the health insurer

1066 to the dentist must include all of the following:

1067 1. The fees, if any, associated with the electronic funds

1068 transfer.

1069 2. The available methods of payment of claims by the health

1070 insurer, with clear instructions to the dentist on how to select

1071 an alternative payment method.

1072 (c) A health insurer that pays a claim to a dentist through

1073 automated clearinghouse transfer is prohibited from charging ~~may~~

1074 ~~not charge~~ a fee solely to transmit the payment to the dentist

1075 unless the dentist has consented to the fee.

1076 (d) This subsection applies to contracts delivered, issued,

1077 or renewed on or after January 1, 2025.

1078 (e) The office has all rights and powers to enforce this

1079 subsection as provided by s. 624.307.

1080 (f) The commission may adopt rules to implement this

1081 subsection.

1082 (26) ~~(21)~~ (a) A health insurer is prohibited from denying ~~may~~

1083 ~~not deny~~ any claim subsequently submitted by a dentist licensed

1084 under chapter 466 for procedures specifically included in a

1085 prior authorization unless at least one of the following

1086 circumstances applies for each procedure denied:

1087 1. Benefit limitations, such as annual maximums and

1088 frequency limitations not applicable at the time of the prior

1089 authorization, are reached subsequent to issuance of the prior

1090 authorization.

1091 2. The documentation provided by the person submitting the

1092 claim fails to support the claim as originally authorized.

1093 3. Subsequent to the issuance of the prior authorization,

1094 new procedures are provided to the patient or a change in the

1095 condition of the patient occurs such that the prior authorized

1096 procedure would no longer be considered medically necessary,

1097 based on the prevailing standard of care.

1098 4. Subsequent to the issuance of the prior authorization,

1099 new procedures are provided to the patient or a change in the

1100 patient’s condition occurs such that the prior authorized

1101 procedure would at that time have required disapproval pursuant

1102 to the terms and conditions for coverage under the patient’s

1103 plan in effect at the time the prior authorization was issued.

1104 5. The denial of the claim was due to one of the following:

1105 a. Another payor is responsible for payment.

1106 b. The dentist has already been paid for the procedures

1107 identified in the claim.

1108 c. The claim was submitted fraudulently, or the prior

1109 authorization was based in whole or material part on erroneous

1110 information provided to the health insurer by the dentist,

1111 patient, or other person not related to the health insurer.

1112 d. The person receiving the procedure was not eligible to

1113 receive the procedure on the date of service.

1114 e. The services were provided during the grace period

1115 established under s. 627.608 or applicable federal regulations,

1116 and the dental insurer notified the provider that the patient

1117 was in the grace period when the provider requested eligibility

1118 or enrollment verification from the dental insurer, if such

1119 request was made.

1120 (b) This subsection applies to all contracts delivered,

1121 issued, or renewed on or after January 1, 2025.

1122 (c) The office has all rights and powers to enforce this

1123 subsection as provided by s. 624.307.

1124 (d) The commission may adopt rules to implement this

1125 subsection.

1126 Section 4. Section 641.3155, Florida Statutes, is amended

1127 to read:

1128 641.3155 Prompt payment of claims.—

1129 (1) As used in this section, the term :

1130 (a) “Claim” for a noninstitutional provider means a paper

1131 HCFA 1500 claim form, or its successor, or an electronic billing

1132 instrument submitted to the health maintenance organization’s

1133 designated location that consists of the ANSI ASC X12N 837P

1134 standard ~~HCFA 1500~~ data set, or its successor, that has all

1135 mandatory entries for a physician licensed under chapter 458,

1136 chapter 459, chapter 460, chapter 461, or chapter 463, or

1137 psychologists licensed under chapter 490 or any appropriate

1138 billing instrument as designated by the provider that has all

1139 mandatory entries for any other noninstitutional provider. For

1140 institutional providers, “claim” means a paper CMS-1450 claim

1141 form, or its successor, or an electronic billing instrument

1142 submitted to the health maintenance organization’s designated

1143 location that consists of the ANSI ASC X12N 837I standard ~~UB-92~~

1144 data set or its successor with entries stated as mandatory by

1145 the National Uniform Billing Committee.

1146 (b) “Clean claim” means a completed form, or completed

1147 electronic billing instrument, containing all information

1148 required under the applicable form or electronic billing

1149 instrument, as well as information reasonably required by the

1150 health maintenance organization, other than for emergency

1151 services and care as defined in s. 641.19, in advance of the

1152 provision of service by the health maintenance organization to

1153 substantiate the claim.

1154 (c) “Electronic medical record” means the digital record of

1155 a patient’s information that may be accessed through electronic

1156 means, via portal or other method of electronic access, which

1157 may include information regarding the patient’s medical history,

1158 medical condition, medical treatment, laboratory results,

1159 diagnostic reports, and clinical notes.

1160 (d) “Emergency health care service” has the same meaning as

1161 “emergency services and care” as defined in s. 641.19.

1162 (e) “Enrollee ineligibility” means that the enrollee was no

1163 longer enrolled in the health maintenance organization at the

1164 time of receiving the applicable service.

1165 (f) “Overpayment” means payment made upon a claim that is:

1166 1. Billed in error;

1167 2. A duplicate claim; or

1168 3. Billed for a service rendered to a patient despite

1169 enrollee ineligibility.

1171 A request for overpayment is limited to a billing error,

1172 duplicate bill, or enrollee ineligibility.

1173 (2) All claims for payment or overpayment, whether

1174 electronic or nonelectronic:

1175 (a) Are considered received on the date the claim is

1176 received by the health maintenance organization at its

1177 designated claims-receipt location or the date the overpayment a

1178 claim ~~for overpayment~~ is received by the provider at its

1179 designated location.

1180 (b) As to providers’ claims for payment, must be mailed or

1181 electronically transferred to the primary organization within 6

1182 months after the following have occurred:

1183 1. Discharge for inpatient services or the date of service

1184 for outpatient services; and

1185 2. The provider has been furnished with the correct name

1186 and address of the patient’s health maintenance organization.

1188 All providers’ claims for payment, whether electronic or

1189 nonelectronic, must be mailed or electronically transferred to

1190 the secondary organization within 45 90 days after final

1191 determination by the primary organization. A provider’s claim is

1192 considered submitted on the date it is electronically

1193 transferred or mailed.

1194 (c) Must not duplicate a claim previously submitted unless

1195 it is determined that the original claim was not received or is

1196 otherwise lost.

1197 (3) For all electronically submitted claims, a health

1198 maintenance organization shall:

1199 (a) Within 24 hours after the beginning of the next

1200 business day after receipt of the claim, provide to the

1201 electronic source submitting the claim an electronic

1202 acknowledgment of the receipt of the claim , accompanied by a

1203 statement indicating the health maintenance organization’s

1204 position as to whether the claim is a clean claim or whether the

1205 claim is missing any information that is required under the

1206 applicable electronic billing instrument described in paragraph

1207 (1)(a) or that was reasonably required by the health maintenance

1208 organization, other than for emergency health care services, in

1209 advance of the provision of service to substantiate ~~to the~~

1210 ~~electronic source submitting~~ the claim , and the health

1211 maintenance organization asserts is missing as of the date of

1212 service .

1213 (b) Within 15 20 days after receipt of the claim, pay the

1214 claim or notify a provider or designee if a claim is denied or

1215 contested. Notice of the health maintenance organization’s

1216 action on the claim and payment of the claim is considered to be

1217 made on the date the notice or payment was received by the

1218 provider ~~mailed~~ or electronically transferred.

1219 (c)1. Notification of the health maintenance organization’s

1220 determination of a contested claim must be accompanied by an

1221 itemized list of any ~~additional~~ information required under the

1222 applicable billing instrument described in paragraph (1)(a) or

1223 that was reasonably required by the health maintenance

1224 organization, other than for emergency health care services, in

1225 advance of the provision of service to substantiate the claim,

1226 and the health maintenance organization asserts is missing as of

1227 the date of such service ~~or documents the insurer can reasonably~~

1228 ~~determine are necessary to process the claim~~ .

1229 2. A provider must submit the additional information or

1230 documentation, as specified on the itemized list, within 30 35

1231 days after receipt of the notification of contestation unless,

1232 within the 30-day period, the provider notifies the health

1233 maintenance organization of the provider’s position that a clean

1234 claim has been submitted . Additional information is considered

1235 submitted on the date it is electronically transferred or

1236 mailed. The health maintenance organization is prohibited from

1237 requesting ~~may not request~~ duplicate documents.

1238 (d) For purposes of this subsection, electronic means of

1239 transmission of claims, notices, documents, forms, and payment

1240 shall be used to the greatest extent possible by the health

1241 maintenance organization and the provider.

1242 (e) A claim contested by the health maintenance

1243 organization must be paid or denied within 30 90 days after

1244 receipt of the additional information requested ~~claim~~ . Failure

1245 to pay or deny a claim within 90 ~~120~~ days after receipt of the

1246 claim , regardless of whether contested by the health maintenance

1247 organization, creates an uncontestable obligation to pay the

1248 claim.

1249 (4) For all nonelectronically submitted claims, a health

1250 maintenance organization shall:

1251 (a) Within 15 days following receipt of the claim ~~Effective~~

1252 ~~November 1, 2003~~ , provide to the provider, or designee, who

1253 submitted the claim:

1254 1. An acknowledgment of receipt of the claim , accompanied

1255 by a statement indicating the health maintenance organization’s

1256 position as to whether the claim is a clean claim or the claim

1257 is missing any information that is required under the applicable

1258 paper billing form, as described in paragraph (1)(a), or that

1259 was reasonably required by the health maintenance organization,

1260 other than for emergency health care services, in advance of the

1261 provision of service to substantiate the claim, and the health

1262 maintenance organization asserts is missing as of the date of

1263 service; or

1264 2. ~~within 15 days after receipt of the claim to the~~

1265 ~~provider or designee or provide a provider or designee within 15~~

1266 ~~days after receipt with~~ Electronic access to the status of the a

1267 submitted claim , which status must indicate the health

1268 maintenance organization’s position as to whether the claim is a

1269 clean claim or missing any information described in subparagraph

1270 1 .

1271 (b) Within 30 40 days after receipt of the claim, pay the

1272 claim or notify a provider or designee if a claim is denied or

1273 contested. Notice of the health maintenance organization’s

1274 action on the claim and payment of the claim is considered to be

1275 made on the date the notice or payment was received by the

1276 provider ~~mailed~~ or electronically transferred.

1277 (c)1. Notification of the health maintenance organization’s

1278 determination of a contested claim must be accompanied by an

1279 itemized list of any ~~additional~~ information required under the

1280 applicable form or billing instrument described in paragraph

1281 (1)(a), or that was reasonably required by the health

1282 maintenance organization, other than for emergency health care

1283 services, in advance of the provision of service to substantiate

1284 the claim, and the health maintenance organization asserts is

1285 missing as of the date of such service ~~or documents the~~

1286 ~~organization can reasonably determine are necessary to process~~

1287 ~~the claim~~ .

1288 2. A provider must submit the additional information or

1289 documentation, as specified on the itemized list, within 30 35

1290 days after receipt of the notification of contestation unless,

1291 within the 30-day period, the provider notifies the health

1292 maintenance organization of the provider’s position that a clean

1293 claim has been submitted . Additional information is considered

1294 submitted on the date it is electronically transferred or

1295 mailed. The health maintenance organization is prohibited from

1296 requesting ~~may not request~~ duplicate documents.

1297 (d) For purposes of this subsection, electronic means of

1298 transmission of claims, notices, documents, forms, and payments

1299 must ~~shall~~ be used to the greatest extent possible by the health

1300 maintenance organization and the provider.

1301 (e) A claim contested by the health maintenance

1302 organization must be paid or denied within 30 ~~120~~ days after

1303 receipt of the additional information requested ~~claim~~ . Failure

1304 to pay or deny a claim within 90 ~~140~~ days after receipt of the

1305 claim , regardless of whether contested by the health maintenance

1306 organization, creates an uncontestable obligation to pay the

1307 claim as submitted by the provider .

1308 (5) Regardless of whether a claim has been submitted

1309 electronically or nonelectronically, and notwithstanding any

1310 other provision of this section:

1311 (a) Once a provider grants a health maintenance

1312 organization access to a patient’s electronic medical record,

1313 the provider is deemed to have supplied all information

1314 necessary to pay the claim, including, without limitation, all

1315 information that is required under the applicable billing

1316 instrument and that was reasonably required by the health

1317 maintenance organization, other than for emergency health care

1318 services, in advance of the provision of service to substantiate

1319 the claim. Additional information or documentation, regardless

1320 of whether the health maintenance organization requests any

1321 additional information, is deemed unnecessary and deemed not

1322 required for payment of the claim, and any request for

1323 additional information, and any position of the health

1324 maintenance organization or any third party acting on behalf of

1325 the health maintenance organization regarding any lack of

1326 information from the provider, is prohibited from being used to

1327 deny, reduce, offset, withhold, pend, or delay payment of the

1328 claim.

1329 (b) If notice of access to the electronic medical record

1330 has been provided to the health maintenance organization, the

1331 claim must be paid or denied within 30 days of such notice to

1332 the health maintenance organization. Failure to pay or deny a

1333 claim, for which the health maintenance organization has been

1334 provided notice of access to the electronic medical record

1335 within 75 days after receipt of such notice, creates an

1336 uncontestable obligation to pay the claim as submitted by the

1337 provider.

1338 (6) ~~(5)~~ If a health maintenance organization determines that

1339 it has made an overpayment to a provider for services rendered

1340 to an enrollee ~~a subscriber~~ , the health maintenance organization

1341 must make an overpayment a claim for such overpayment to the

1342 provider’s designated location. A health maintenance

1343 organization that makes an overpayment a claim ~~for overpaymen~~ t

1344 to a provider under this section shall give the provider a

1345 written or electronic statement specifying the basis for the

1346 retrospective ~~retroactive~~ denial or payment adjustment. The

1347 health maintenance organization must also identify the claim or

1348 claims, or ~~overpayment claim~~ portion thereof, as to which the

1349 health maintenance organization alleges overpayment, and the

1350 specific invoice number submitted with or on the claim, as well

1351 as the specific line items on the bill that are subject to the

1352 overpayment claim ~~for which a claim for overpayment is~~

1353 ~~submitted~~ . Except as provided in subparagraph (a)3., there may

1354 be no denial, reduction, offset, withholding, pending, or delay

1355 of payment, or other negative impact, regardless of whether by

1356 the health maintenance organization or any third party acting on

1357 behalf of such health maintenance organization, on payment of

1358 any other claim of the provider on the basis of the overpayment

1359 allegation.

1360 (a) If an overpayment determination is the result of

1361 retrospective ~~retroactive~~ review or retrospective audit of

1362 ~~coverage decisions or payment levels not related to fraud~~ , a

1363 health maintenance organization must ~~shall~~ adhere to the

1364 following procedures:

1365 1. All overpayment claims ~~for overpayment~~ must be received

1366 by the ~~submitted to a~~ provider within 18 30 months after the

1367 health maintenance organization’s payment of the claim. A

1368 provider must pay, deny, or contest the health maintenance

1369 organization’s overpayment claim ~~for overpayment~~ within 40 days

1370 after the receipt of the overpayment claim. All contested

1371 overpayment claims ~~for overpayment~~ must be paid or denied within

1372 120 days after receipt of the overpayment claim. Failure to pay

1373 or deny an overpayment ~~and~~ claim within 140 days after receipt

1374 creates an uncontestable obligation to pay the overpayment

1375 claim.

1376 2. A provider that denies or contests a health maintenance

1377 organization’s overpayment claim ~~for overpayment~~ or any portion

1378 of an overpayment a claim shall notify the health maintenance

1379 organization, in writing, within 40 35 days after the provider

1380 receives the overpayment claim that the overpayment claim ~~for~~

1381 ~~overpayment~~ is contested or denied. The notice that the

1382 overpayment claim ~~for overpayment~~ is denied or contested must

1383 identify the denied or contested portion of the claim and the

1384 specific reason for contesting or denying the overpayment claim

1385 and, if contested, must include a request for additional

1386 information. If the health maintenance organization submits

1387 additional information, the health maintenance organization

1388 must, within 35 days after receipt of the request, mail or

1389 electronically transfer the information to the provider. The

1390 provider shall pay or deny the overpayment claim ~~for overpayment~~

1391 within 45 days after receipt of the information. The notice from

1392 the provider regarding denial or contestation of the overpayment

1393 claim is considered made on the date the notice is mailed or

1394 electronically transferred by the provider.

1395 3. The health maintenance organization is prohibited from

1396 denying, reducing, offsetting, withholding, pending, or delaying

1397 ~~may not reduce~~ payment to the provider for other services unless

1398 the provider agrees to the denial, reduction , offset,

1399 withholding, pending, or delay of payment in writing or fails to

1400 respond to the health maintenance organization’s overpayment

1401 claim as required by this paragraph.

1402 4. Payment of an overpayment claim is considered made on

1403 the date the payment was mailed or electronically transferred.

1404 An overdue payment of a claim bears simple interest at the rate

1405 of 12 percent per year. Interest on an overdue payment for an

1406 overpayment a claim ~~for an overpayment payment~~ begins to accrue

1407 when the overpayment claim should have been paid ~~, denied, or~~

1408 ~~contested~~ .

1409 (b) An overpayment A claim is prohibited ~~for overpayment~~

1410 ~~shall not be permitted~~ beyond 18 30 months after the health

1411 maintenance organization’s payment of a claim, except that

1412 overpayment claims ~~for overpayment~~ may be sought beyond that

1413 time from providers convicted of fraud pursuant to s. 817.234.

1414 (7) ~~(6)~~ Payment of a claim is considered made on the date

1415 the payment was mailed or electronically transferred to the

1416 provider . An overdue payment of a claim bears simple interest of

1417 15 12 percent per year , to be calculated on the full total

1418 amount that should have been paid on the claim within the

1419 applicable time period specified in this section. If an

1420 applicable court, arbitration tribunal, or other binding legal

1421 process determines that a claim that was paid at a lesser amount

1422 should have been paid at a full total amount, whether under a

1423 breach of contract legal claim, a legal claim under a statutory

1424 private cause of action, or other basis, the 15 percent per year

1425 interest must be calculated on the full total amount, rather

1426 than upon the difference between the full total amount and the

1427 amount that was actually paid. If an applicable court,

1428 arbitration tribunal, or other binding legal process determines

1429 that a claim was subject to an inappropriate or impermissible

1430 denial or partial denial, whether in a breach of contract,

1431 statute, common law, or otherwise, interest must be calculated

1432 on the full total amount that should have been paid on the claim

1433 within the applicable time period for payment specified in this

1434 section, and the act of denial or partial denial is deemed not

1435 to have in any way tolled the time period for such payment .

1436 Interest on the full total amount that should have been paid on

1437 the claim within the applicable time period specified in this

1438 section ~~an overdue payment for a claim or for any portion of a~~

1439 ~~claim~~ begins to accrue when the claim should have been paid ,

1440 ~~denied, or contested~~ . The interest must be paid along with, and

1441 in addition to, the payment for the satisfaction of the full

1442 total amount of the claim, as determined by an applicable court,

1443 arbitration tribunal, or other binding legal process ~~is payable~~

1444 ~~with the payment of the claim~~ .

1445 (8) ~~(7)~~ For all contracts entered into or renewed on or

1446 after October 1, 2002, a health maintenance organization’s

1447 internal dispute resolution process related to a denied claim

1448 not under active review by a mediator, arbitrator, or third

1449 party dispute entity must be finalized within 60 days after the

1450 receipt of the provider’s request for review or appeal.

1451 Notwithstanding any provision of this section, if the provider

1452 and health maintenance organization disagree as to the

1453 interpretation of contractual or statutory language, the

1454 provider is not required to participate in the health

1455 maintenance organization’s internal dispute resolution process.

1456 (9) ~~(8)~~ A provider or any representative of a provider,

1457 regardless of whether the provider is under contract with the

1458 health maintenance organization, is prohibited from collecting

1459 or attempting ~~may not collect or attempt~~ to collect money from,

1460 maintaining ~~maintain~~ any action at law against, or reporting

1461 ~~report~~ to a credit agency an enrollee ~~a subscriber~~ for payment

1462 of covered services for which the health maintenance

1463 organization contested or denied the provider’s claim. This

1464 prohibition applies during the pendency of any claim for payment

1465 made by the provider to the health maintenance organization for

1466 payment of the services or internal dispute resolution process

1467 to determine whether the health maintenance organization is

1468 liable for the services. For a claim, this pendency applies from

1469 the date the claim or a portion of the claim is denied to the

1470 date of the completion of the health maintenance organization’s

1471 internal dispute resolution process, not to exceed 60 days. This

1472 subsection does not prohibit collection by the provider of

1473 copayments, coinsurance, or deductible amounts due the provider.

1474 ~~(9) The provisions of this section may not be waived,~~

1475 ~~voided, or nullified by contract.~~

1476 (10) A health maintenance organization is prohibited from

1477 retrospectively denying ~~may not retroactively deny~~ a claim

1478 because of enrollee ~~subscriber~~ ineligibility more than 90 days 1

1479 ~~year~~ after the date of payment of the claim.

1480 (11) A health maintenance organization must ~~shall~~ pay a

1481 contracted primary care or admitting physician, pursuant to such

1482 physician’s contract, for providing inpatient services in a

1483 contracted hospital to an enrollee ~~a subscriber~~ if such services

1484 are determined by the primary care physician or admitting

1485 physician ~~health maintenance organization~~ to be medically

1486 necessary and such services are covered services under the

1487 health maintenance organization’s contract with the contract

1488 holder.

1489 (12) A permissible error ratio of 5 percent is established

1490 for health maintenance organizations’ claims payment violations

1491 of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c),

1492 and (e). If the error ratio of a particular health maintenance

1493 organization ~~insurer~~ does not exceed the permissible error ratio

1494 of 5 percent for an audit period, no fine may ~~shall~~ be assessed

1495 for the noted claims violations for the audit period. The error

1496 ratio is ~~shall be~~ determined by dividing the number of claims

1497 with violations found on a statistically valid sample of claims

1498 for the audit period by the total number of claims in the

1499 sample. If the error ratio exceeds the permissible error ratio

1500 of 5 percent, a fine may be assessed according to s. 624.4211

1501 for those claims payment violations which exceed the error

1502 ratio. Notwithstanding the provisions of this section, the

1503 office may fine a health maintenance organization for claims

1504 payment violations of paragraphs (3)(e) and (4)(e) which create

1505 an uncontestable obligation to pay the claim as submitted by the

1506 provider . The office shall refrain from imposing a ~~not~~ fine upon

1507 a health maintenance organization ~~organizations~~ for violations

1508 which the office determines were due to circumstances beyond the

1509 organization’s control.

1510 (13) This section applies ~~shall apply~~ to all claims or any

1511 portion of a claim submitted for payment for services provided

1512 to an enrollee by a ~~health maintenance organization subscriber~~

1513 under a health maintenance organization plan, or submitted for

1514 payment for services provided to an enrollee under a self

1515 insured plan or fund, or fully-insured plan or fund, offered by

1516 a person or an entity, when a health maintenance organization is

1517 involved in the administration, or claims-processing activities,

1518 relating to such plan or fund ~~subscriber contract to the~~

1519 ~~organization for payment~~ .

1520 (14) Notwithstanding paragraph (3)(b), where an electronic

1521 pharmacy claim is submitted to a pharmacy benefits manager

1522 acting on behalf of a health maintenance organization, the

1523 pharmacy benefits manager must ~~shall~~ , within 30 days after of

1524 receipt of the claim, pay the claim or notify a provider or

1525 designee if a claim is denied or contested. Notice of the health

1526 maintenance organization’s action on the claim and payment of

1527 the claim is considered to be made on the date the notice or

1528 payment was received by the provider ~~mailed~~ or electronically

1529 transferred.

1530 (15) Notwithstanding paragraph (4)(a), effective November

1531 1, 2003, where a nonelectronic pharmacy claim is submitted to a

1532 pharmacy benefits manager acting on behalf of a health

1533 maintenance organization, the pharmacy benefits manager shall

1534 provide acknowledgment of receipt of the claim within 30 days

1535 after receipt of the claim to the provider or provide a provider

1536 within 30 days after receipt with electronic access to the

1537 status of a submitted claim.

1538 (16) Notwithstanding the 18-month ~~30-month~~ period provided

1539 in subsection (6) ~~(5)~~ , all claims for overpayment submitted to a

1540 provider licensed under chapter 395, chapter 458, chapter 459,

1541 chapter 460, chapter 461, chapter 463, chapter 466, or chapter

1542 490 must be submitted to the provider within 12 months after the

1543 health maintenance organization’s payment of the claim. An

1544 overpayment A claim to a provider licensed under chapter 395,

1545 458, chapter 459, chapter 460, chapter 461, chapter 463, chapter

1546 466, or chapter 490 is prohibited ~~for overpayment may not be~~

1547 ~~permitted~~ beyond 12 months after the health maintenance

1548 organization’s payment of a claim, except that claims for

1549 overpayment may be sought beyond that time from providers

1550 convicted of fraud pursuant to s. 817.234.

1551 (17) Notwithstanding any other provision of this section,

1552 all claims for underpayment from a provider licensed under

1553 chapter 395, chapter 458, chapter 459, chapter 460, chapter 461,

1554 or chapter 466 must be submitted to the health maintenance

1555 organization within 12 months after the health maintenance

1556 organization’s payment of the claim. A claim for underpayment by

1557 a provider licensed under chapter 395, chapter 458, chapter 459,

1558 chapter 460, chapter 461, or chapter 466 is prohibited ~~may not~~

1559 ~~be permitted~~ beyond 12 months after the health maintenance

1560 organization’s payment of a claim.

1561 (18) Nothing in this section may be interpreted to limit,

1562 restrict, or negatively impact any legal claim by a provider or

1563 health maintenance organization for breach of contract,

1564 statutory or regulatory violation, or a common-law cause of

1565 action, nor to shorten or otherwise negatively impact the

1566 statute of limitations timeframe for bringing any such legal

1567 claim.

1568 (19) A health insurer is prohibited from requesting

1569 information from a contracted or noncontracted provider which

1570 does not apply to the medical condition at issue for the

1571 purposes of adjudicating a clean claim.

1572 (20) A health maintenance organization is prohibited from

1573 requesting a contracted or noncontracted provider to resubmit

1574 claim information that the contracted or noncontracted provider

1575 can document it has already provided to the health maintenance

1576 organization or that is contained inside the electronic medical

1577 record to which the health maintenance organization has been

1578 provided access.

1579 (21) Notwithstanding any other provision of this section, a

1580 health maintenance organization is prohibited from requiring any

1581 information from a provider before the provision of emergency

1582 health care services as a condition of payment of a claim, as a

1583 basis for denying, delaying, offsetting, withholding, or

1584 reducing payment of a claim, or in contesting whether the claim

1585 is a clean claim.

1586 (22) For a violation of this section, a provider shall have

1587 a private cause of action to proceed against the health

1588 maintenance organization in the applicable tribunal for the

1589 violation.

1590 Section 5. Paragraph (c) of subsection (2) of section

1591 395.1065, Florida Statutes, is amended to read:

1592 395.1065 Criminal and administrative penalties;

1593 moratorium.—

1594 (2)

1595 (c) The agency may impose an administrative fine for the

1596 violation of s. 641.3154 or, if sufficient claims due to a

1597 provider from a health maintenance organization do not exist to

1598 enable the take-back of an overpayment, as provided under s.

1599 641.3155(6) ~~s. 641.3155(5)~~ , for the violation of s. 641.3155(6)

1600 ~~s. 641.3155(5)~~ . The administrative fine for a violation cited in

1601 this paragraph shall be in the amounts specified in s.

1602 641.52(5), and the provisions of paragraph (a) do not apply.

1603 Section 6. This act shall take effect July 1, 2026.