HB 805 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to overpayment claims by health 2
insurers; amending s. 627.6131, F.S.; revising the 3
timeframe for overpayment claims by health insurers 4
against providers; providing applicability of such 5
timeframe to overpayment claims as a result of 6
specified retroactive review or audit; creating s. 7
627.65725, F.S.; providing requirements for 8
overpayment claims that are sent to providers by 9
insurers issuing group, blanket, and franchise health 10
insurance policies; providing timeframes for 11
submissions of overp ayment claims; providing 12
applicability of specified timeframes; providing 13
timeframes and procedures for paying, denying, and 14
contesting overpayment claims and for submitting 15
certain information; prohibiting insurers from 16
reducing certain payments to provid ers; providing 17
exceptions; providing the date of payment of 18
overpayment claims; providing interest rates and 19
interest accrual start dates; amending s. 641.3155, 20
F.S.; revising the timeframes for overpayment claims 21
by health maintenance organizations agains t providers; 22
providing applicability of such timeframe to 23
overpayment claims as a result of specified 24
retroactive review or audit; providing an effective 25
HB 805 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
date. 26
27
Be It Enacted by the Legislature of the State of Florida: 28
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Section 1. Subsection (19) o f section 627.6131, Florida 30
Statutes, is renumbered as subsection (18), and subsection (6) 31
and present subsection (18) of that section are amended to read: 32
627.6131 Payment of claims. — 33
(6) If a health insurer determines that it has made an 34
overpayment to a provider for services rendered to an insured, 35
the health insurer must make a claim for such overpayment to the 36
provider's designated location. A health insurer that makes a 37
claim for overpayment to a provider under this section shall 38
give the provider a written or electronic statement specifying 39
the basis for the retroactive denial or payment adjustment. The 40
insurer must identify the claim or claims, or overpayment claim 41
portion thereof, for which a claim for overpayment is submitted. 42
(a)1. Except as provided in subparagraph 2., a claim for 43
overpayment must be submitted to a provider within 12 months 44
after the health insurer's payment of the claim. The 12 -month 45
timeframe applies to claims that include, but are not limited 46
to: 47
a. Any claim for overpa yment as a result of a retroactive 48
review or audit of coverage decisions or payment levels not 49
related to fraud, as described in paragraph (b); or 50
HB 805 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
b. Any claim for overpayment submitted to a provider 51
licensed under chapter 458, chapter 459, chapter 460, chapter 52
461, or chapter 466. 53
2.(b) A claim for overpayment shall not be permitted 54
beyond 30 months after the health insurer's payment of a claim, 55
except that claims for overpayment may be sought beyond 12 56
months after the health insurer's payment of the claim to a 57
provider that time from providers convicted of fraud pursuant to 58
s. 817.234. 59
(b)(a) If an overpayment determination is the result of 60
retroactive review or audit of coverage decisions or payment 61
levels not related to fraud, a provider and a health insurer 62
shall adhere to the following procedures: 63
1. The All claims for overpayment must be submitted to a 64
provider within 30 months after the health insurer's payment of 65
the claim. A provider must pay, deny, or contest the health 66
insurer's claim for overpayment within 40 days after the receipt 67
of the claim. All contested claims for overpayment must be paid 68
or denied within 120 days after receipt of the claim. Failure to 69
pay or deny overpayment and claim within 140 days after receipt 70
creates an uncontestable obligation to pay the claim. 71
2. A provider that denies or contests a health insurer's 72
claim for overpayment or any portion of a claim shall notify the 73
health insurer, in writing, within 35 days after the provider 74
receives the claim that the claim for overpayment is contested 75
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or denied. The notice that the claim for overpayment is denied 76
or contested must identify the contested portion of the claim 77
and the specific reason for contesting or denying the claim and, 78
if contested, must include a request for additional information. 79
If the health insurer submits additional information, the health 80
insurer must, within 35 days after receipt of the request, mail 81
or electronically transfer the information to the provider. The 82
provider shall pay or deny the cla im for overpayment within 45 83
days after receipt of the information. The notice is considered 84
made on the date the notice is mailed or electronically 85
transferred by the provider. 86
3. The health insurer may not reduce payment to the 87
provider for other servi ces unless the provider agrees to the 88
reduction in writing or fails to respond to the health insurer's 89
overpayment claim as required by this paragraph. 90
4. Payment of an overpayment claim is considered made on 91
the date the payment was mailed or electronic ally transferred. 92
An overdue payment of a claim bears simple interest at the rate 93
of 12 percent per year. Interest on an overdue payment for a 94
claim for an overpayment begins to accrue when the claim should 95
have been paid, denied, or contested. 96
(18) Notwithstanding the 30 -month period provided in 97
subsection (6), all claims for overpayment submitted to a 98
provider licensed under chapter 458, chapter 459, chapter 460, 99
chapter 461, or chapter 466 must be submitted to the provider 100
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
within 12 months after the health insurer's payment of the 101
claim. A claim for overpayment may not be permitted beyond 12 102
months after the health insurer's payment of a claim, except 103
that claims for overpayment may be sought beyond that time from 104
providers convicted of fraud pursuant to s. 817.234. 105
Section 2. Section 627.65725, Florida Statutes, is created 106
to read: 107
627.65725 Overpayment claims. —If an insurer issuing a 108
group, blanket, or franchise health insurance policy determines 109
that it has made an overpayment to a pro vider for services 110
rendered to an insured, the insurer must make a claim for such 111
overpayment to the provider's designated location. An insurer 112
issuing a group, blanket, or franchise health policy that makes 113
a claim for overpayment to a provider shall give the provider a 114
written or electronic statement specifying the basis for the 115
retroactive denial or payment adjustment. The insurer must 116
identify the claim or claims, or overpayment claim portion 117
thereof, for which a claim for overpayment is submitted. 118
(1)(a) Except as provided in paragraph (b), a claim for 119
overpayment must be submitted to a provider within 12 months 120
after the insurer's payment of the claim. The 12 -month timeframe 121
applies to claims that include, but are not limited to: 122
1. Any claim for overpayment as a result of a retroactive 123
review or audit of coverage decisions or payment levels not 124
related to fraud, as described in subsection (2); or 125
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2. Any claim for overpayment submitted to a provider 126
licensed under chapter 458, chapter 459, chapter 460, chapter 127
461, or chapter 466. 128
(b) A claim for overpayment may be sought beyond 12 months 129
after the insurer's payment of the claim to a provider convicted 130
of fraud pursuant to s. 817.234. 131
(2) If an overpayment determination is the result of 132
retroactive review or audit of coverage decisions or payment 133
levels not related to fraud, a provider and the insurer shall 134
adhere to the following procedures: 135
(a) The provider must pay, deny, or contest the insurer's 136
claim for overpayment within 40 days after r eceipt of the claim. 137
All contested claims for overpayment must be paid or denied 138
within 120 days after receipt of the claim. Failure to pay or 139
deny overpayment and claim within 140 days after receipt creates 140
an uncontestable obligation to pay the claim. 141
(b) A provider that denies or contests the insurer's claim 142
for overpayment or any portion of a claim shall notify the 143
insurer, in writing, within 35 days after the provider receives 144
the claim that the claim for overpayment is contested or denied. 145
The notice that the claim for overpayment is denied or contested 146
must identify the contested portion of the claim and the 147
specific reason for contesting or denying the claim and, if 148
contested, must include a request for additional information. If 149
the insurer submits additional information, the insurer must, 150
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within 35 days after receipt of the request, mail or 151
electronically transfer the information to the provider. The 152
provider shall pay or deny the claim for overpayment within 45 153
days after receipt of the informati on. The notice is considered 154
made on the date the notice is mailed or electronically 155
transferred by the provider. 156
(c) The insurer may not reduce payment to the provider for 157
other services unless the provider agrees to the reduction in 158
writing or fails to respond to the insurer's overpayment claim 159
as required by this subsection. 160
(d) Payment of an overpayment claim is considered made on 161
the date the payment was mailed or electronically transferred. 162
An overdue payment of a claim bears simple interest at th e rate 163
of 12 percent per year. Interest on an overdue payment for a 164
claim for an overpayment begins to accrue when the claim should 165
have been paid, denied, or contested. 166
Section 3. Subsection (17) of section 641.3155, Florida 167
Statutes, is renumbered as subsection (16), and subsection (5) 168
and present subsection (16) of that section are amended to read: 169
641.3155 Prompt payment of claims. — 170
(5) If a health maintenance organization determines that 171
it has made an overpayment to a provider for services ren dered 172
to a subscriber, the health maintenance organization must make a 173
claim for such overpayment to the provider's designated 174
location. A health maintenance organization that makes a claim 175
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for overpayment to a provider under this section shall give the 176
provider a written or electronic statement specifying the basis 177
for the retroactive denial or payment adjustment. The health 178
maintenance organization must identify the claim or claims, or 179
overpayment claim portion thereof, for which a claim for 180
overpayment is submitted. 181
(a)1. Except as provided in subparagraph 2., a claim for 182
overpayment must be submitted to a provider within 12 months 183
after the health maintenance organization's payment of the 184
claim. The 12-month timeframe applies to claims that include, 185
but are not limited to: 186
a. Any claim for overpayment as a result of a retroactive 187
review or audit of coverage decisions or payment levels not 188
related to fraud, as described in paragraph (b); or 189
b. Any claim for overpayment submitted to a provider 190
licensed under chapter 458, chapter 459, chapter 460, chapter 191
461, or chapter 466. 192
2.(b) A claim for overpayment shall not be permitted 193
beyond 30 months after the health maintenance organization's 194
payment of a claim, except that claims for overpayment may be 195
sought beyond 12 months after the health maintenance 196
organization's payment of the claim to a provider that time from 197
providers convicted of fraud pursuant to s. 817.234. 198
(b)(a) If an overpayment determination is the result of 199
retroactive review or audit o f coverage decisions or payment 200
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
levels not related to fraud, a provider and a health maintenance 201
organization shall adhere to the following procedures: 202
1. The All claims for overpayment must be submitted to a 203
provider within 30 months after the health ma intenance 204
organization's payment of the claim. A provider must pay, deny, 205
or contest the health maintenance organization's claim for 206
overpayment within 40 days after the receipt of the claim. All 207
contested claims for overpayment must be paid or denied with in 208
120 days after receipt of the claim. Failure to pay or deny 209
overpayment and claim within 140 days after receipt creates an 210
uncontestable obligation to pay the claim. 211
2. A provider that denies or contests a health maintenance 212
organization's claim for o verpayment or any portion of a claim 213
shall notify the organization, in writing, within 35 days after 214
the provider receives the claim that the claim for overpayment 215
is contested or denied. The notice that the claim for 216
overpayment is denied or contested mus t identify the contested 217
portion of the claim and the specific reason for contesting or 218
denying the claim and, if contested, must include a request for 219
additional information. If the organization submits additional 220
information, the organization must, withi n 35 days after receipt 221
of the request, mail or electronically transfer the information 222
to the provider. The provider shall pay or deny the claim for 223
overpayment within 45 days after receipt of the information. The 224
notice is considered made on the date the notice is mailed or 225
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electronically transferred by the provider. 226
3. The health maintenance organization may not reduce 227
payment to the provider for other services unless the provider 228
agrees to the reduction in writing or fails to respond to the 229
health maintenance organization's overpayment claim as required 230
by this paragraph. 231
4. Payment of an overpayment claim is considered made on 232
the date the payment was mailed or electronically transferred. 233
An overdue payment of a claim bears simple interest at the ra te 234
of 12 percent per year. Interest on an overdue payment for a 235
claim for an overpayment payment begins to accrue when the claim 236
should have been paid, denied, or contested. 237
(16) Notwithstanding the 30 -month period provided in 238
subsection (5), all claims for overpayment submitted to a 239
provider licensed under chapter 458, chapter 459, chapter 460, 240
chapter 461, or chapter 466 must be submitted to the provider 241
within 12 months after the health maintenance organization's 242
payment of the claim. A claim for overp ayment may not be 243
permitted beyond 12 months after the health maintenance 244
organization's payment of a claim, except that claims for 245
overpayment may be sought beyond that time from providers 246
convicted of fraud pursuant to s. 817.234. 247
Section 4. This act shall take effect July 1, 2022. 248