CS/CS/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 notify a dentist if initiating or changing 6
electronic funds transfer payment methods for dental 7
claims; prohibiting a health insurer from charging a 8
fee to transmit a payment to a dentist throu gh an 9
automated clearinghouse transfer unless the dentist 10
has consented to such fee; authorizing a health 11
insurer to charge certain fees; providing 12
applicability; authorizing the Office of Insurance 13
Regulation of the Financial Services Commission to 14
enforce certain provisions; authorizing the commission 15
to adopt rules; prohibiting a health insurer from 16
denying claims for procedures included in a prior 17
authorization; providing exceptions; providing 18
applicability; authorizing the office to enforce 19
certain provisions; authorizing the commission to 20
adopt rules; amending s. 636.032, F.S.; prohibiting a 21
contract between a prepaid limited health service 22
organization and a dentist from containing certain 23
restrictions on payment methods; requiring a prepaid 24
limited health service organization to notify a 25
CS/CS/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
dentist if initiating or changing electronic funds 26
transfer payment methods for dental claims; 27
prohibiting a prepaid limited health service 28
organization from charging a fee to transmit a payment 29
to a dentist through a n automated clearinghouse 30
transfer unless the dentist has consented to such fee; 31
authorizing a prepaid limited health service 32
organization to charge certain fees; providing 33
applicability; authorizing the office to enforce 34
certain provisions; authorizing th e commission to 35
adopt rules; amending s. 636.035, F.S.; prohibiting a 36
prepaid limited health service organization from 37
denying claims for procedures included in a prior 38
authorization; providing exceptions; providing 39
applicability; amending s. 641.315, F.S. ; prohibiting 40
a contract between a health maintenance organization 41
and a dentist from containing certain restrictions on 42
payment methods; requiring a health maintenance 43
organization to notify a dentist if initiating or 44
changing electronic funds transfer pa yment methods for 45
dental claims; prohibiting a health maintenance 46
organization from charging a fee to transmit a payment 47
to a dentist through an automated clearinghouse 48
transfer unless the dentist has consented to such fee; 49
authorizing a health maintenance organization to 50
CS/CS/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
charge certain fees; providing applicability; 51
authorizing the office to enforce certain provisions; 52
authorizing the commission to adopt rules; prohibiting 53
a health maintenance organization from denying claims 54
for procedures included in a p rior authorization; 55
providing exceptions; providing applicability; 56
authorizing the office to enforce certain provisions; 57
authorizing the commission to adopt rules; providing 58
an effective date. 59
60
Be It Enacted by the Legislature of the State of Florida : 61
62
Section 1. Subsections (20) and (21) are added to section 63
627.6131, Florida Statutes, to read: 64
627.6131 Payment of claims. — 65
(20)(a) A contract between a health insurer and a dentist 66
licensed under chapter 466 for the provision of services to an 67
insured may not require credit card payment as the only 68
acceptable method for payments from the health insurer to the 69
dentist. 70
(b) If initiating or changing payments to a dentist using 71
electronic funds transfer payments, including, but not limited 72
to, virtual credit card payments, a health insurer shall notify 73
the dentist in writing of all of the following: 74
1. The fees, if any, associated with the electronic funds 75
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transfer. 76
2. The available methods of payment of claims by the 77
health insurer, with clea r instructions to the dentist on how to 78
select an alternative payment method, if any. 79
(c) A health insurer that pays a claim to a dentist 80
through an automated clearinghouse transfer may not charge a fee 81
solely to transmit the payment to the dentist unles s the dentist 82
has consented to the fee. A health insurer may charge reasonable 83
fees for value-added services related to the transfer, 84
including, but not limited to, transaction management, data 85
management, and portal services. 86
(d) This subsection applies to contracts delivered, 87
issued, or renewed on or after January 1, 2025. 88
(e) The office has all rights and powers to enforce this 89
subsection as provided by s. 624.307. 90
(f) The commission may adopt rules to implement this 91
subsection. 92
(21)(a) A health insurer may not deny any claim 93
subsequently submitted by a dentist licensed under chapter 466 94
for procedures specifically included in a prior authorization 95
unless at least one of the following circumstances applies for 96
each procedure denied: 97
1. Benefit limitations, such as annual maximums and 98
frequency limitations not applicable at the time of the prior 99
authorization, are reached subsequent to issuance of the prior 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
authorization. 101
2. The documentation provided by the person submitting the 102
claim fails to support the claim as originally authorized. 103
3. Subsequent to the issuance of the prior authorization, 104
new procedures are provided to the patient or a change in the 105
patient's condition occurs such that the prior authorized 106
procedure would no longer be considered medically necessary, 107
based on the prevailing standard of care. 108
4. Subsequent to the issuance of the prior authorization, 109
new procedures are provided to the patient or a change in the 110
patient's condition occurs such that the prior authorized 111
procedure would at that time have required disapproval pursuant 112
to the terms and conditions for coverage under the patient's 113
plan in effect at the time the prior authorization was issued. 114
5. The denial of the claim was due to o ne of the 115
following: 116
a. Another payor is responsible for payment. 117
b. The dentist has already been paid for the procedures 118
identified in the claim. 119
c. The claim was submitted fraudulently, or the prior 120
authorization was based in whole or material part on erroneous 121
information provided to the health insurer by the dentist, 122
patient, or other person not related to the insurer. 123
d. The person receiving the procedure was not eligible to 124
receive the procedure on the date of service. 125
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e. The services were p rovided during the grace period 126
established under s. 627.608 or applicable federal regulations, 127
and the health insurer notified the dentist that the patient was 128
in the grace period when the dentist requested eligibility or 129
enrollment verification from the health insurer, if such request 130
was made. 131
(b) This subsection applies to contracts delivered, 132
issued, or renewed on or after January 1, 2025. 133
(c) The office has all rights and powers to enforce this 134
subsection as provided by s. 624.307. 135
(d) The commission may adopt rules to implement this 136
subsection. 137
Section 2. Section 636.032, Florida Statutes, is amended 138
to read: 139
636.032 Acceptable payments. — 140
(1) Each prepaid limited health service organization may 141
accept from government agencies, corporatio ns, groups, or 142
individuals payments covering all or part of the cost of 143
contracts entered into between the prepaid limited health 144
service organization and its subscribers. 145
(2)(a) A contract between a prepaid limited health service 146
organization and a dent ist licensed under chapter 466 for the 147
provision of services to a subscriber may not require credit 148
card payment as the only acceptable method for payments from the 149
prepaid limited health service organization to the dentist. 150
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(b) If initiating or changing payments to a dentist using 151
electronic funds transfer payments, including, but not limited 152
to, virtual credit card payments, a prepaid limited health 153
service organization shall notify the dentist in writing of all 154
of the following: 155
1. The fees, if any, associated with the electronic funds 156
transfer. 157
2. The available methods of payment of claims by the 158
prepaid limited health service organization, with clear 159
instructions to the dentist on how to select an alternative 160
payment method, if any. 161
(c) A prepaid limited health service organization that 162
pays a claim to a dentist through an automated clearinghouse 163
transfer may not charge a fee solely to transmit the payment to 164
the dentist unless the dentist has consented to the fee. A 165
prepaid limited health servic e organization may charge 166
reasonable fees for value -added services related to the 167
transfer, including, but not limited to, transaction management, 168
data management, and portal services. 169
(d) This subsection applies to contracts delivered, 170
issued, or renewed on or after January 1, 2025. 171
(e) The office has all rights and powers to enforce this 172
subsection as provided by s. 624.307. 173
(f) The commission may adopt rules to implement this 174
subsection. 175
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Section 3. Subsection (15) is added to section 636.035, 176
Florida Statutes, to read: 177
636.035 Provider arrangements. — 178
(15)(a) A prepaid limited health service organization may 179
not deny any claim subsequently submitted by a dentist licensed 180
under chapter 466 for procedures specifically included in a 181
prior authorization unless at least one of the following 182
circumstances applies for each procedure denied: 183
1. Benefit limitations, such as annual maximums and 184
frequency limitations not applicable at the time of the prior 185
authorization, are reached subsequent to issua nce of the prior 186
authorization. 187
2. The documentation provided by the person submitting the 188
claim fails to support the claim as originally authorized. 189
3. Subsequent to the issuance of the prior authorization, 190
new procedures are provided to the patient o r a change in the 191
patient's condition occurs such that the prior authorized 192
procedure would no longer be considered medically necessary, 193
based on the prevailing standard of care. 194
4. Subsequent to the issuance of the prior authorization, 195
new procedures are provided to the patient or a change in the 196
patient's condition occurs such that the prior authorized 197
procedure would at that time have required disapproval pursuant 198
to the terms and conditions for coverage under the patient's 199
plan in effect at the time t he prior authorization was issued. 200
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5. The denial of the dental service claim was due to one 201
of the following: 202
a. Another payor is responsible for payment. 203
b. The dentist has already been paid for the procedures 204
identified in the claim. 205
c. The claim was submitted fraudulently, or the prior 206
authorization was based in whole or material part on erroneous 207
information provided to the prepaid limited health service 208
organization by the dentist, patient, or other person not 209
related to the organi zation. 210
d. The person receiving the procedure was not eligible to 211
receive the procedure on the date of service. 212
e. The services were provided during the grace period 213
established under s. 636.016 or applicable federal regulations, 214
and the prepaid limited health service organization notified the 215
dentist that the patient was in the grace period when the 216
dentist requested eligibility or enrollment verification from 217
the prepaid limited health service organization, if such request 218
was made. 219
(b) This subsection applies to contracts delivered, 220
issued, or renewed on or after January 1, 2025. 221
Section 4. Subsections (13) and (14) are added to section 222
641.315, Florida Statutes, to read: 223
641.315 Provider contracts. — 224
(13)(a) A contract between a health maintenance 225
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organization and a dentist licensed under chapter 466 for the 226
provision of services to a subscriber of the health maintenance 227
organization may not require credit card payment as the only 228
acceptable method for payments from the health maintenance 229
organization to the dentist. 230
(b) If initiating or changing payments to a dentist using 231
electronic funds transfer payments, including, but not limited 232
to, virtual credit card payments, a health maintenance 233
organization shall notify the dentist in writing of all of the 234
following: 235
1. The fees, if any, associated with the electronic funds 236
transfer. 237
2. The available methods of payment of claims by the 238
health maintenance organization, with clear instructions to the 239
dentist on how to selec t an alternative payment method, if any. 240
(c) A health maintenance organization that pays a claim to 241
a dentist through an automated clearinghouse transfer may not 242
charge a fee solely to transmit the payment to the dentist 243
unless the dentist has consented to the fee. A health 244
maintenance organization may charge reasonable fees for value -245
added services related to the transfer, including, but not 246
limited to, transaction management, data management, and portal 247
services. 248
(d) This subsection applies to contrac ts delivered, 249
issued, or renewed on or after January 1, 2025. 250
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(e) The office has all rights and powers to enforce this 251
subsection as provided by s. 624.307. 252
(f) The commission may adopt rules to implement this 253
subsection. 254
(14)(a) A health maintenance organization may not deny any 255
claim subsequently submitted by a dentist licensed under chapter 256
466 for procedures specifically included in a prior 257
authorization unless at least one of the following circumstances 258
applies for each procedure denied: 259
1. Benefit limitations, such as annual maximums and 260
frequency limitations not applicable at the time of the prior 261
authorization, are reached subsequent to issuance of the prior 262
authorization. 263
2. The documentation provided by the person submitting the 264
claim fails to support the claim as originally authorized. 265
3. Subsequent to the issuance of the prior authorization, 266
new procedures are provided to the patient or a change in the 267
patient's condition occurs such that the prior authorized 268
procedure would no longer be considered medically necessary, 269
based on the prevailing standard of care. 270
4. Subsequent to the issuance of the prior authorization, 271
new procedures are provided to the patient or a change in the 272
patient's condition occurs such that the prior authorized 273
procedure would at that time have required disapproval pursuant 274
to the terms and conditions for coverage under the patient's 275
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plan in effect at the time the prior authorization was issued. 276
5. The denial of the claim was due to one of the 277
following: 278
a. Another payor is responsible for payment. 279
b. The dentist has already been paid for the procedures 280
identified in the claim. 281
c. The claim was submitted fraudulently, or the prior 282
authorization was based in whole or material part on erroneous 283
information provided to the health maintenance organization by 284
the dentist, patient, or other person not related to the 285
organization. 286
d. The person receiving the procedure was not eligible to 287
receive the procedure on the date of service. 288
e. The services were provi ded during the grace period 289
established under s. 641.31 or applicable federal regulations, 290
and the health maintenance organization notified the dentist 291
that the patient was in the grace period when the dentist 292
requested eligibility or enrollment verificati on from the health 293
maintenance organization, if such request was made. 294
(b) This subsection applies to contracts delivered, 295
issued, or renewed on or after January 1, 2025. 296
(c) The office has all rights and powers to enforce this 297
subsection as provided by s. 624.307. 298
(d) The commission may adopt rules to implement this 299
subsection. 300
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Section 5. This act shall take effect July 1, 2024. 301