Florida Senate - 2022 SB 440 By Senator Harrell 25-00704-22 2022440__ 1 A bill to be entitled 2 An act relating to overpayment of claims; amending ss. 3 627.6131 and 641.3155, F.S.; revising the timeframe 4 for submission of insurer and health maintenance 5 organization claims, respectively, for overpayment to 6 providers; conforming provisions to changes made by 7 the act; providing an effective date. 8 9 Be It Enacted by the Legislature of the State of Florida: 10 11 Section 1.Subsections (6) and (18) of section 627.6131, 12 Florida Statutes, are amended to read: 13 627.6131Payment of claims. 14 (6)If a health insurer determines that it has made an 15 overpayment to a provider for services rendered to an insured, 16 the health insurer must make a claim for such overpayment to the 17 providers designated location. A health insurer that makes a 18 claim for overpayment to a provider under this section shall 19 give the provider a written or electronic statement specifying 20 the basis for the retroactive denial or payment adjustment. The 21 insurer must identify the claim or claims, or overpayment claim 22 portion thereof, for which a claim for overpayment is submitted. 23 (a)If an overpayment determination is the result of 24 retroactive review or audit of coverage decisions or payment 25 levels not related to fraud, a health insurer shall adhere to 26 the following procedures: 27 1.All claims for overpayment must be submitted to a 28 provider within 12 30 months after the health insurers payment 29 of the claim. A provider must pay, deny, or contest the health 30 insurers claim for overpayment within 40 days after the receipt 31 of the claim. All contested claims for overpayment must be paid 32 or denied within 120 days after receipt of the claim. Failure to 33 pay or deny overpayment and claim within 140 days after receipt 34 creates an uncontestable obligation to pay the claim. 35 2.A provider that denies or contests a health insurers 36 claim for overpayment or any portion of a claim shall notify the 37 health insurer, in writing, within 35 days after the provider 38 receives the claim that the claim for overpayment is contested 39 or denied. The notice that the claim for overpayment is denied 40 or contested must identify the contested portion of the claim 41 and the specific reason for contesting or denying the claim and, 42 if contested, must include a request for additional information. 43 If the health insurer submits additional information, the health 44 insurer must, within 35 days after receipt of the request, mail 45 or electronically transfer the information to the provider. The 46 provider shall pay or deny the claim for overpayment within 45 47 days after receipt of the information. The notice is considered 48 made on the date the notice is mailed or electronically 49 transferred by the provider. 50 3.The health insurer may not reduce payment to the 51 provider for other services unless the provider agrees to the 52 reduction in writing or fails to respond to the health insurers 53 overpayment claim as required by this paragraph. 54 4.Payment of an overpayment claim is considered made on 55 the date the payment was mailed or electronically transferred. 56 An overdue payment of a claim bears simple interest at the rate 57 of 12 percent per year. Interest on an overdue payment for a 58 claim for an overpayment begins to accrue when the claim should 59 have been paid, denied, or contested. 60 (b)A claim for overpayment shall not be permitted beyond 61 30 months after the health insurers payment of a claim, except 62 that Claims for overpayment may be sought beyond the 12-month 63 period provided in this subsection that time from providers 64 convicted of fraud pursuant to s. 817.234. 65 (18)Notwithstanding the 30-month period provided in 66 subsection (6), all claims for overpayment submitted to a 67 provider licensed under chapter 458, chapter 459, chapter 460, 68 chapter 461, or chapter 466 must be submitted to the provider 69 within 12 months after the health insurers payment of the 70 claim. A claim for overpayment may not be permitted beyond 12 71 months after the health insurers payment of a claim, except 72 that claims for overpayment may be sought beyond that time from 73 providers convicted of fraud pursuant to s. 817.234. 74 Section 2.Subsections (5) and (16) of section 641.3155, 75 Florida Statutes, are amended to read: 76 641.3155Prompt payment of claims. 77 (5)If a health maintenance organization determines that it 78 has made an overpayment to a provider for services rendered to a 79 subscriber, the health maintenance organization must make a 80 claim for such overpayment to the providers designated 81 location. A health maintenance organization that makes a claim 82 for overpayment to a provider under this section shall give the 83 provider a written or electronic statement specifying the basis 84 for the retroactive denial or payment adjustment. The health 85 maintenance organization must identify the claim or claims, or 86 overpayment claim portion thereof, for which a claim for 87 overpayment is submitted. 88 (a)If an overpayment determination is the result of 89 retroactive review or audit of coverage decisions or payment 90 levels not related to fraud, a health maintenance organization 91 shall adhere to the following procedures: 92 1.All claims for overpayment must be submitted to a 93 provider within 12 30 months after the health maintenance 94 organizations payment of the claim. A provider must pay, deny, 95 or contest the health maintenance organizations claim for 96 overpayment within 40 days after the receipt of the claim. All 97 contested claims for overpayment must be paid or denied within 98 120 days after receipt of the claim. Failure to pay or deny 99 overpayment and claim within 140 days after receipt creates an 100 uncontestable obligation to pay the claim. 101 2.A provider that denies or contests a health maintenance 102 organizations claim for overpayment or any portion of a claim 103 shall notify the organization, in writing, within 35 days after 104 the provider receives the claim that the claim for overpayment 105 is contested or denied. The notice that the claim for 106 overpayment is denied or contested must identify the contested 107 portion of the claim and the specific reason for contesting or 108 denying the claim and, if contested, must include a request for 109 additional information. If the organization submits additional 110 information, the organization must, within 35 days after receipt 111 of the request, mail or electronically transfer the information 112 to the provider. The provider shall pay or deny the claim for 113 overpayment within 45 days after receipt of the information. The 114 notice is considered made on the date the notice is mailed or 115 electronically transferred by the provider. 116 3.The health maintenance organization may not reduce 117 payment to the provider for other services unless the provider 118 agrees to the reduction in writing or fails to respond to the 119 health maintenance organizations overpayment claim as required 120 by this paragraph. 121 4.Payment of an overpayment claim is considered made on 122 the date the payment was mailed or electronically transferred. 123 An overdue payment of a claim bears simple interest at the rate 124 of 12 percent per year. Interest on an overdue payment for a 125 claim for an overpayment payment begins to accrue when the claim 126 should have been paid, denied, or contested. 127 (b)A claim for overpayment shall not be permitted beyond 128 30 months after the health maintenance organizations payment of 129 a claim, except that Claims for overpayment may be sought beyond 130 the 12-month period provided in this subsection that time from 131 providers convicted of fraud pursuant to s. 817.234. 132 (16)Notwithstanding the 30-month period provided in 133 subsection (5), all claims for overpayment submitted to a 134 provider licensed under chapter 458, chapter 459, chapter 460, 135 chapter 461, or chapter 466 must be submitted to the provider 136 within 12 months after the health maintenance organizations 137 payment of the claim. A claim for overpayment may not be 138 permitted beyond 12 months after the health maintenance 139 organizations payment of a claim, except that claims for 140 overpayment may be sought beyond that time from providers 141 convicted of fraud pursuant to s. 817.234. 142 Section 3.This act shall take effect July 1, 2022.