HB 1219 2024
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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 dental insurance claims; amending 2
s. 627.6131, F.S.; prohibiting a contract between a 3
health insurer and a dentist from containing certain 4
restrictions on payment methods; requiring a health 5
insurer to make certain notifications before p aying a 6
claim to a dentist through electronic funds transfer; 7
prohibiting a health insurer from charging a fee to 8
transmit a payment to a dentist through ACH transfer 9
unless the dentist has consented to such fee; 10
authorizing a health insurer to charge reas onable fees 11
for other value-added services related to the ACH 12
transfer; providing construction; authorizing the 13
Office of Insurance Regulation of the Financial 14
Services Commission to enforce certain provisions; 15
authorizing the commission to adopt rules; pr ohibiting 16
a health insurer from denying claims for procedures 17
included in a prior authorization; providing 18
exceptions; providing construction; authorizing the 19
office to enforce certain provisions; authorizing the 20
commission to adopt rules; amending s. 627. 6474, F.S.; 21
revising the definition of the term "covered 22
services"; amending s. 636.032, F.S.; prohibiting a 23
contract between a prepaid limited health service 24
organization and a dentist from containing certain 25
HB 1219 2024
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hb1219-00
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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
restrictions on payment methods; requiring the prepaid 26
limited health service organization to make certain 27
notifications before paying a claim to a dentist 28
through electronic funds transfer; prohibiting a 29
prepaid limited health service organization from 30
charging a fee to transmit a payment to a dentis t 31
through ACH transfer unless the dentist has consented 32
to such fee; authorizing the prepaid limited health 33
service organization to charge reasonable fees for 34
other value-added services related to the ACH 35
transfer; providing construction; authorizing the 36
office to enforce certain provisions; authorizing the 37
commission to adopt rules; amending s. 636.035, F.S.; 38
revising the definition of the term "covered 39
services"; prohibiting a prepaid limited health 40
service organization from denying claims for 41
procedures included in a prior authorization; 42
providing exceptions; providing construction; 43
authorizing the office to enforce certain provisions; 44
authorizing the commission to adopt rules; amending s. 45
641.315, F.S.; revising the definition of the term 46
"covered service"; prohibiting a contract between a 47
health maintenance organization and a dentist from 48
containing certain restrictions on payment methods; 49
requiring the health maintenance organization to make 50
HB 1219 2024
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hb1219-00
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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
certain notifications before paying a claim to a 51
dentist through electronic funds transfer; prohibiting 52
a health maintenance organization from charging a fee 53
to transmit a payment to a dentist through ACH 54
transfer unless the dentist has consented to such fee; 55
authorizing the health maintenance organization to 56
charge reasonable fees for other value -added services 57
related to the ACH transfer; providing construction; 58
authorizing the office to enforce certain provisions; 59
authorizing the commission to adopt rules; prohibiting 60
a health maintenance organization from denying claims 61
for procedures included in a prior authorization; 62
providing exceptions; providing construction; 63
authorizing the office to enforce certain provisions; 64
authorizing the commission to adopt rules; providing 65
an effective date. 66
67
Be It Enacted by the Legislature of the State of Florida: 68
69
Section 1. Subsections (20) and (21) are added to section 70
627.6131, Florida Statutes, to read: 71
627.6131 Payment of claims. — 72
(20)(a) A contract between a health insurer and a dentist 73
licensed under chapter 466 for the provision of services to an 74
insured may not specify credit card payment as the only 75
HB 1219 2024
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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
acceptable method for payments from the health insurer to the 76
dentist. 77
(b) At least 10 days before a health insurer pays a claim 78
to a dentist through electronic f unds transfer, including, but 79
not limited to, virtual credit card payments, the health insurer 80
shall notify the dentist in writing of all of the following: 81
1. The fees, if any, associated with the electronic funds 82
transfer. 83
2. The available methods of payment of claims by the 84
health insurer, with clear instructions to the dentist on how to 85
select an alternative payment method. 86
(c) A health insurer that pays a claim to a dentist 87
through Automated Clearing House (ACH) transfer may not charge a 88
fee solely to transmit the payment to the dentist unless the 89
dentist has consented to the fee. A health insurer may charge 90
reasonable fees for other value -added services related to the 91
ACH transfer, including, but not limited to, transaction 92
management, data manage ment, and portal services. 93
(d) This subsection may not be waived, voided, or 94
nullified by contract, and any contractual clause in conflict 95
with this subsection or which purports to waive any requirements 96
of this subsection is null and void. 97
(e) The office has all rights and powers to enforce this 98
subsection as provided by s. 624.307. 99
(f) The commission may adopt rules to implement this 100
HB 1219 2024
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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
subsection. 101
(21)(a) A health insurer may not deny any claim 102
subsequently submitted by a dentist licensed under chap ter 466 103
for procedures specifically included in a prior authorization 104
unless at least one of the following circumstances applies for 105
each procedure denied: 106
1. Benefit limitations, such as annual maximums and 107
frequency limitations not applicable at the ti me of the prior 108
authorization, are reached subsequent to issuance of the prior 109
authorization. 110
2. The documentation provided by the person submitting the 111
claim fails to support the claim as originally authorized. 112
3. Subsequent to the issuance of the prior authorization, 113
new procedures are provided to the patient or a change in the 114
condition of the patient occurs such that the prior authorized 115
procedure would no longer be considered medically necessary, 116
based on the prevailing standard of care. 117
4. Subsequent to the issuance of the prior authorization, 118
new procedures are provided to the patient or a change in the 119
patient's condition occurs such that the prior authorized 120
procedure would at that time have required disapproval pursuant 121
to the terms and conditions for coverage under the patient's 122
plan in effect at the time the prior authorization was issued. 123
5. The denial of the claim was due to one of the 124
following: 125
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a. Another payor is responsible for payment. 126
b. The dentist has already been paid for the procedures 127
identified in the claim. 128
c. The claim was submitted fraudulently, or the prior 129
authorization was based in whole or material part on erroneous 130
information provided to the health insurer by the dentist, 131
patient, or other person not related to the insurer. 132
d. The person receiving the procedure was not eligible to 133
receive the procedure on the date of service and the health 134
insurer did not know, and with the exercise of reasonable care 135
could not have known, of his or her ineligibility. 136
(b) This subsection may not be waived, voided, or 137
nullified by contract, and any contractual clause in conflict 138
with this subsection or which purports to waive any requirements 139
of this subsection is null and void. 140
(c) The office has all rights and powers to enforce this 141
subsection as provided by s. 624.307. 142
(d) The commission may adopt rules to implement this 143
subsection. 144
Section 2. Subsection (2) of section 627.6474, Florida 145
Statutes, is amended to read: 146
627.6474 Provider contracts. — 147
(2) A contract between a health insurer and a dentist 148
licensed under chapter 466 for the provision of services to an 149
insured may not contain a provision that requires the dentist to 150
HB 1219 2024
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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
provide services to the insured under such contract at a fee set 151
by the health insurer un less such services are covered services 152
under the applicable contract. As used in this subsection, the 153
term "covered services" means dental care services for which a 154
reimbursement is available under the insured's contract, 155
notwithstanding or for which a reimbursement would be available 156
but for the application of contractual limitations , such as 157
deductibles, coinsurance, waiting periods, annual or lifetime 158
maximums, frequency limitations, alternative benefit payments, 159
or any other limitation. 160
Section 3. Section 636.032, Florida Statutes, is amended 161
to read: 162
636.032 Acceptable payments. — 163
(1) Each prepaid limited health service organization may 164
accept from government agencies, corporations, groups, or 165
individuals payments covering all or part of the cos t of 166
contracts entered into between the prepaid limited health 167
service organization and its subscribers. 168
(2)(a) A contract between a prepaid limited health service 169
organization and a dentist licensed under chapter 466 for the 170
provision of services to a s ubscriber may not specify credit 171
card payment as the only acceptable method for payments from the 172
prepaid limited health service organization to the dentist. 173
(b) At least 10 days before a limited health service 174
organization pays a claim to a dentist thro ugh electronic funds 175
HB 1219 2024
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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
transfer, including, but not limited to, virtual credit card 176
payments, the prepaid limited health service organization shall 177
notify the dentist in writing of all of the following: 178
1. The fees, if any, that are associated with the 179
electronic funds transfer. 180
2. The available methods of payment of claims by the 181
prepaid limited health service organization, with clear 182
instructions to the dentist on how to select an alternative 183
payment method. 184
(c) A prepaid limited health service organi zation that 185
pays a claim to a dentist through Automatic Clearing House (ACH) 186
transfer may not charge a fee solely to transmit the payment to 187
the dentist unless the dentist has consented to the fee. A 188
prepaid limited health service organization may charge 189
reasonable fees for other value -added services related to the 190
ACH transfer, including, but not limited to, transaction 191
management, data management, and portal services. 192
(d) This subsection may not be waived, voided, or 193
nullified by contract, and any contr actual clause in conflict 194
with this subsection or which purports to waive any requirements 195
of this subsection is null and void. 196
(e) The office has all rights and powers to enforce this 197
subsection as provided by s. 624.307. 198
(f) The commission may adopt rules to implement this 199
subsection. 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
Section 4. Subsection (13) of section 636.035, Florida 201
Statutes, is amended, and subsection (15) is added to that 202
section, to read: 203
636.035 Provider arrangements. — 204
(13) A contract between a prepaid limited health service 205
organization and a dentist licensed under chapter 466 for the 206
provision of services to a subscriber of the prepaid limited 207
health service organization may not contain a provision that 208
requires the dentist to provide services to the subscriber of 209
the prepaid limited health service organization at a fee set by 210
the prepaid limited health service organization unless such 211
services are covered services under the applicable contract. As 212
used in this subsection, the term "covered services" means 213
dental care services for which a reimbursement is available 214
under the subscriber's contract, notwithstanding or for which a 215
reimbursement would be available but for the application of 216
contractual limitations such as deductibles, coinsurance, 217
waiting periods, annual or lifetime maximums, frequency 218
limitations, alternative benefit payments, or any other 219
limitation. 220
(15)(a) A prepaid limited health service organization may 221
not deny any claim subsequently submitted by a dentist licensed 222
under chapter 466 for procedures specifically included in a 223
prior authorization unless at least one of the following 224
circumstances applies for each procedure denied: 225
HB 1219 2024
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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
1. Benefit limitations, such as annual maximums and 226
frequency limitations not applicable at the time of the prior 227
authorization, are reached subsequent to issuance of the prior 228
authorization. 229
2. The documentation provided by the person submitting the 230
claim fails to support the claim as originally authorized. 231
3. Subsequent to the issuance of the prior authorization, 232
new procedures are provided to the patient or a change in the 233
condition of the patient occurs such that the prior authorized 234
procedure would no longer be considered medically necessary, 235
based on the prevailing standard of care. 236
4. Subsequent to the issuance of the prior authorization, 237
new procedures are provided to the patient or a change in the 238
patient's condition occurs such that the prior authorized 239
procedure would at that time have required disapproval pursuant 240
to the terms and conditio ns for coverage under the patient's 241
plan in effect at the time the prior authorization was issued. 242
5. The denial of the dental service claim was due to one 243
of the following: 244
a. Another payor is responsible for payment. 245
b. The dentist has already been paid for the procedures 246
identified in the claim. 247
c. The claim was submitted fraudulently, or the prior 248
authorization was based in whole or material part on erroneous 249
information provided to the prepaid limited health service 250
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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
organization by the dentist, patient, or other person not 251
related to the organization. 252
d. The person receiving the procedure was not eligible to 253
receive the procedure on the date of service and the prepaid 254
limited health service organization did not know, and with the 255
exercise of reasonable care could not have known, of his or her 256
ineligibility. 257
(b) This subsection may not be waived, voided, or 258
nullified by contract, and any contractual clause in conflict 259
with this subsection or which purports to waive any requirements 260
of this subsection is null and void. 261
(c) The office has all rights and powers to enforce this 262
subsection as provided by s. 624.307. 263
(d) The commission may adopt rules to implement this 264
subsection. 265
Section 5. Subsection (11) of section 641.315, Florida 266
Statutes, is amended, and subsections (13) and (14) are added to 267
that section, to read: 268
641.315 Provider contracts. — 269
(11) A contract between a health maintenance organization 270
and a dentist licensed under chapter 466 for the provision of 271
services to a subscrib er of the health maintenance organization 272
may not contain a provision that requires the dentist to provide 273
services to the subscriber of the health maintenance 274
organization at a fee set by the health maintenance organization 275
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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
unless such services are covere d services under the applicable 276
contract. As used in this subsection, the term "covered 277
services" means dental care services for which a reimbursement 278
is available under the subscriber's contract, notwithstanding or 279
for which a reimbursement would be avail able but for the 280
application of contractual limitations such as deductibles, 281
coinsurance, waiting periods, annual or lifetime maximums, 282
frequency limitations, alternative benefit payments, or any 283
other limitation. 284
(13)(a) A contract between a health main tenance 285
organization and a dentist licensed under chapter 466 for the 286
provision of services to a subscriber of the health maintenance 287
organization may not specify credit card payment as the only 288
acceptable method for payments from the health maintenance 289
organization to the dentist. 290
(b) At least 10 days before a health maintenance 291
organization pays a claim to a dentist through electronic funds 292
transfer, including, but not limited to, virtual credit card 293
payments, the health maintenance organization shall n otify the 294
dentist in writing of all of the following: 295
1. The fees, if any, that are associated with the 296
electronic funds transfer. 297
2. The available methods of payment of claims by the 298
health maintenance organization, with clear instructions to the 299
dentist on how to select an alternative payment method. 300
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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
(c) A health maintenance organization that pays a claim to 301
a dentist through Automated Clearing House (ACH) transfer may 302
not charge a fee solely to transmit the payment to the dentist 303
unless the dentist has consented to the fee. A health 304
maintenance organization may charge reasonable fees for other 305
value-added services related to the ACH transfer, including, but 306
not limited to, transaction management, data management, and 307
portal services. 308
(d) This subsection may not be waived, voided, or 309
nullified by contract, and any contractual clause in conflict 310
with this subsection or which purports to waive any requirements 311
of this subsection is null and void. 312
(e) The office has all rights and powers to enforce t his 313
subsection as provided by s. 624.307. 314
(f) The commission may adopt rules to implement this 315
subsection. 316
(14)(a) A health maintenance organization may not deny any 317
claim subsequently submitted by a dentist licensed under chapter 318
466 for procedures sp ecifically included in a prior 319
authorization unless at least one of the following circumstances 320
applies for each procedure denied: 321
1. Benefit limitations, such as annual maximums and 322
frequency limitations not applicable at the time of the prior 323
authorization, are reached subsequent to issuance of the prior 324
authorization. 325
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2. The documentation provided by the person submitting the 326
claim fails to support the claim as originally authorized. 327
3. Subsequent to the issuance of the prior authorization, 328
new procedures are provided to the patient or a change in the 329
condition of the patient occurs such that the prior authorized 330
procedure would no longer be considered medically necessary, 331
based on the prevailing standard of care. 332
4. Subsequent to the issuance of the prior authorization, 333
new procedures are provided to the patient or a change in the 334
patient's condition occurs such that the prior authorized 335
procedure would at that time have required disapproval pursuant 336
to the terms and conditions for coverage under the patient's 337
plan in effect at the time the prior authorization was issued. 338
5. The denial of the claim was due to one of the 339
following: 340
a. Another payor is responsible for payment. 341
b. The dentist has already been paid for the procedures 342
identified in the claim. 343
c. The claim was submitted fraudulently, or the prior 344
authorization was based in whole or material part on erroneous 345
information provided to the health maintenance organization by 346
the dentist, patient, or other person not related to the 347
organization. 348
d. The person receiving the procedure was not eligible to 349
receive the procedure on the date of service and the health 350
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maintenance organization did not know, and with the exercise of 351
reasonable care could not have known, of his or her 352
ineligibility. 353
(b) The subsection may not be waived, voided, or nullified 354
by contract, and any contractual clause in conflict with this 355
subsection or which purports to waive any requirements of this 356
subsection is null and void. 357
(c) The office has all rights and powers to enforce this 358
subsection as provided by s. 624.307. 359
(d) The commission may adopt rules to implement this 360
subsection. 361
Section 6. This act shall take effect July 1, 2024. 362