Florida 2024 Regular Session

Florida House Bill H1475 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
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3	3	HB 1475 2024
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7	7	CODING: Words stricken are deletions; words underlined are additions.
8	8	hb1475-00
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10	10	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
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14	14	A bill to be entitled 1
15	15	An act relating to health care services; amending s. 2
16	16	627.42392, F.S.; defining terms; revising the 3
17	17	definitions of the terms "health insurer" as 4
18	18	"utilization review entity"; requiring utilization 5
19	19	review entities to establish and offer a prior 6
20	20	authorization process for accepting electronic prior 7
21	21	authorization requests by a specified date; specifying 8
22	22	a requirement for the process; specifying additional 9
23	23	requirements and procedures for, and restrictions and 10
24	24	limitations on, utilization review entities relating 11
25	25	to prior authorization for covered health care 12
26	26	benefits; defining the term "medications for opioid 13
27	27	use disorder"; providing construction; creating s. 14
28	28	627.4262, F.S.; defining terms; prohibiting payment 15
29	29	adjudicators from downcoding health care services 16
30	30	under certain circumstances; requiring payment 17
31	31	adjudicators to provide certain information prior to 18
32	32	making their initial payment or notice of denial of 19
33	33	payment; prohibiting downcoding by payment 20
34	34	adjudicators for certain orders; providing that a 21
35	35	payment adjudicator is solely responsible for certain 22
36	36	violations of law; requiring payment adjudicators to 23
37	37	maintain downcoding policies on their websites; 24
38	38	specifying the requirements of such policies; 25
39	39
40	40	HB 1475 2024
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45	45	hb1475-00
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47	47	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
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49	49
50	50
51	51	providing that payment adjudicators are responsible 26
52	52	for compliance with certain provisions; requiring 27
53	53	payment adjudicators to develop certain internal 28
54	54	procedures; authorizing the Office of Insurance 29
55	55	Regulation to investigate and take appropriate actions 30
56	56	under certain circumstances; providing severability; 31
57	57	authorizing a provide r to bring a private cause of 32
58	58	action under certain circumstances; amending s. 33
59	59	627.6131, F.S.; revising the requirements of insurer 34
60	60	contracts; revising the definition of the term 35
61	61	"claim"; defining terms; revising the requirements for 36
62	62	health insurers submitt ing claims electronically and 37
63	63	nonelectronically; making technical changes; deleting 38
64	64	the prohibition against waiving, voiding, or 39
65	65	nullifying certain provisions by contract; prohibiting 40
66	66	a health insurer from retrospectively denying a claim 41
67	67	under certain circumstances; revising procedures for 42
68	68	investigation of claims of improper billing; providing 43
69	69	construction; prohibiting health care insurers from 44
70	70	requesting certain information or resubmission of 45
71	71	claims under certain circumstances; prohibiting an 46
72	72	insurer from requiring information from a provider 47
73	73	before the provision of emergency services and care; 48
74	74	providing an effective date. 49
75	75	50
76	76
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84	84	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
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86	86
87	87
88	88	Be It Enacted by the Legislature of the State of Florida: 51
89	89	52
90	90	Section 1. Section 627.42392, Florida Statutes, is amended 53
91	91	to read: 54
92	92	627.42392 Prior authorization. — 55
93	93	(1) As used in this section, the term : 56
94	94	(a) "Adverse determination" means a decision by a health 57
95	95	insurer or utilization review entity to deny, reduce, or 58
96	96	terminate health care services furnished or proposed to be 59
97	97	furnished to an insured. The term does not include a decision to 60
98	98	deny, reduce, or terminate services that were determined to be 61
99	99	duplicate bills or that are confirmed with the provider to have 62
100	100	been billed in error. 63
101	101	(b) "Electronic prior authorization process" does not 64
102	102	include transmissions through a facsimile machine. 65
103	103	(c) "Emergency health care services" has the same meaning 66
104	104	as "emergency services and care" as defined in s. 395.002. 67
105	105	(d) "Prior authorization" means the process by which 68
106	106	health insurers, thir d-party payors, or utilization review 69
107	107	entities determine the medical necessity of nonemergency health 70
108	108	care services before the rendering of such services by the 71
109	109	provider. Such prior authorization is authorized by the 72
110	110	applicable agreement with the health ca re provider or such prior 73
111	111	authorization is otherwise obtained by a provider that does not 74
112	112	have such an agreement. The term also includes a health 75
113	113
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121	121	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
122	122
123	123
124	124
125	125	insurer's or utilization review entity's requirement, if such 76
126	126	requirement is permitted by the applicable agree ment with a 77
127	127	health care provider or otherwise permitted by a health care 78
128	128	provider that does not have such an agreement, that a patient or 79
129	129	health care provider notify the health insurer or utilization 80
130	130	review entity before the provision of a nonemergency hea lth care 81
131	131	service. 82
132	132	(e) "Urgent health care service" means a health care 83
133	133	service to treat a medical condition that, if the timeframe for 84
134	134	making a nonexpedited prior authorization were to be applied, 85
135	135	could, in the opinion of a physician with knowledge of th e 86
136	136	patient's medical condition: 87
137	137	1. Seriously jeopardize the life or health of the patient 88
138	138	or the ability of the patient to regain maximum function; or 89
139	139	2. Subject the patient to severe pain that cannot be 90
140	140	adequately managed without the care, treatment, o r prescription 91
141	141	drug that is the subject of the prior authorization request. 92
142	142	(f) "Utilization review activity" means any action taken 93
143	143	prospective to, concurrent with, or retrospective to the 94
144	144	provision of nonemergency health care services to determine 95
145	145	whether a claim is paid or is subject to an adverse 96
146	146	determination. Utilization review activity is not allowed to the 97
147	147	extent restricted or prohibited by an agreement with a health 98
148	148	care provider or, other than to verify a presenting emergency 99
149	149	medical condition, for emergency health care services. For 100
150	150
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158	158	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
159	159
160	160
161	161
162	162	purposes of this paragraph, the term "a presenting emergency 101
163	163	medical condition" means a medical condition manifesting itself 102
164	164	by acute symptoms of sufficient severity, including severe pain, 103
165	165	such that a prudent layper son who possesses an average knowledge 104
166	166	of health and medicine could reasonably expect the absence of 105
167	167	immediate medical attention to result in a condition or 106
168	168	situation described in s. 395.002(8). 107
169	169	(g) "Utilization review entity" "health insurer" means an 108
170	170	authorized insurer offering health insurance as defined in s. 109
171	171	624.603, a managed care plan as defined in s. 409.962(10), or a 110
172	172	health maintenance organization as defined in s. 641.19(12) , a 111
173	173	pharmacy benefit manager as defined in s. 624.490, or any other 112
174	174	individual or entity that provides, offers to provide, or 113
175	175	administers payment for hospital services, outpatient services, 114
176	176	medical services, prescription drugs, or other health care 115
177	177	services to a person treated by a health care professional or 116
178	178	facility in this state under a policy, plan, or contract . 117
179	179	(2) Beginning January 1, 2025, a utilization review entity 118
180	180	shall establish and offer a secure, interactive, online, 119
181	181	electronic prior authorization process for accepting electronic 120
182	182	prior authorization requests. The process must allow a person 121
183	183	seeking prior authorization the ability to upload documentation 122
184	184	if such documentation is required by the utilization review 123
185	185	entity to make a determination on the prior authorization 124
186	186	request. 125
187	187
188	188	HB 1475 2024
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195	195	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
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197	197
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199	199	(3) Notwithstanding any other provision of law, effective 126
200	200	January 1, 2017, or 6 six (6) months after the effective date of 127
201	201	the rule adopting the prior authorization form, whichever is 128
202	202	later, a utilization review entity that health insurer, or a 129
203	203	pharmacy benefits manager on behalf of th e health insurer, which 130
204	204	does not provide an electronic prior authorization process for 131
205	205	use by its contracted providers , shall use only use the prior 132
206	206	authorization form that has been approved by the Financial 133
207	207	Services commission for granting a prior authori zation for a 134
208	208	medical procedure, course of treatment, or prescription drug 135
209	209	benefit. Such form may not exceed two pages in length, excluding 136
210	210	any instructions or guiding documentation, and must include all 137
211	211	clinical documentation necessary for the utilization review 138
212	212	entity health insurer to make a decision. At a minimum, the form 139
213	213	must include: 140
214	214	(a)(1) Sufficient patient information to identify the 141
215	215	member, date of birth, full name, and health plan ID number; 142
216	216	(b)(2) The provider's provider name, address, and phone 143
217	217	number; 144
218	218	(c)(3) The medical procedure, course of treatment, or 145
219	219	prescription drug benefit being requested, including the medical 146
220	220	reason therefor, and all services tried and failed; 147
221	221	(d)(4) Any laboratory documentation required; and 148
222	222	(e)(5) An attestation that all information provided is 149
223	223	true and accurate. 150
224	224
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232	232	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
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236	236	(4)(3) The Financial Services commission, in consultation 151
237	237	with the Agency for Health Care Administration , shall adopt by 152
238	238	rule guidelines for all prior authorization forms which ensure 153
239	239	the general uniformity of such forms. 154
240	240	(5)(4) Electronic prior authorization approvals do not 155
241	241	preclude benefit verification or medical review by the 156
242	242	utilization review entity insurer under either the medical or 157
243	243	pharmacy benefits. 158
244	244	(6) A utilization review entity's prior authorization 159
245	245	process may not require information that is not needed to make a 160
246	246	determination or facilitate a determination of medical necessity 161
247	247	of the requested medical procedure, course of treatment, or 162
248	248	prescription drug benefit. 163
249	249	(7) A utilization review entity shall disclose all of its 164
250	250	prior authorization requirements and restrictions, including any 165
251	251	written clinical criteria, in a publicly accessible manner o n 166
252	252	its website. Such information must be explained in detail and in 167
253	253	clear and ordinary terms. 168
254	254	(8) A utilization review entity may not implement any new 169
255	255	requirement or restriction or make changes to existing 170
256	256	requirements for or restrictions on obtaining pr ior 171
257	257	authorization unless both of the following conditions are met: 172
258	258	(a) The changes have been available on a publicly 173
259	259	accessible website for at least 60 days before they are 174
260	260	implemented. 175
261	261
262	262	HB 1475 2024
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269	269	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
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272	272
273	273	(b) Insureds and health care providers affected by the new 176
274	274	requirements and restrictions or by the changes to the 177
275	275	requirements and restrictions are provided with a written notice 178
276	276	of the changes at least 60 days before they are implemented. 179
277	277	Such notice must be delivered electronically or by other means 180
278	278	as agreed to by the insured or the health care provider. 181
279	279	(9) A utilization review entity shall make available on 182
280	280	its website, in a readily accessible format, data regarding 183
281	281	prior authorization approvals and denials, which must include 184
282	282	all of the following: 185
283	283	(a) All items and services requiring prior authorization. 186
284	284	(b) The percentage, in aggregate, of prior authorization 187
285	285	requests approved. 188
286	286	(c) The percentage, in aggregate, of prior authorization 189
287	287	requests denied. 190
288	288	(d) The percentage of prior authorization requests 191
289	289	approved after appeal. 192
290	290	(e) The percentage of prior authorization requests in 193
291	291	which the timeframe for review was extended and the prior 194
292	292	authorization request was approved. 195
293	293	(f) The percentage of expedited prior authorization 196
294	294	requests approved. 197
295	295	(g) The average and median time between submission of a 198
296	296	request for prior authorization and a determination of the 199
297	297	outcome. 200
298	298
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306	306	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
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310	310	(h) The average and median time between submission of a 201
311	311	request for an expedited prior authorization and a determination 202
312	312	of the outcome. 203
313	313	204
314	314	This subsection does not apply to the expansion of health care 205
315	315	services coverage. 206
316	316	(10) A utilization review entity shall ensure that all 207
317	317	adverse determinations are made by a physician licensed pursuant 208
318	318	to chapter 458 or chapter 459. All of the following requi rements 209
319	319	apply to such physicians: 210
320	320	(a) The physician must possess a current and valid 211
321	321	nonrestricted license to practice medicine in this state. 212
322	322	(b) The physician must be of the same specialty as the 213
323	323	physician who typically manages the medical condition or disease 214
324	324	or who provides the health care service that is the subject of 215
325	325	the request. 216
326	326	(c) The physician must have experience treating patients 217
327	327	with the medical condition or disease for which the health care 218
328	328	service is being requested. 219
329	329	(11) Notice of an adverse determination must be provided 220
330	330	by e-mail to the health care provider that initiated the prior 221
331	331	authorization. The notice must include all of the following: 222
332	332	(a) The name, title, e -mail address, and telephone number 223
333	333	of the physician responsible for making the adverse 224
334	334	determination. 225
335	335
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343	343	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
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347	347	(b) Any written clinical criteria and any internal rule, 226
348	348	guideline, or protocol that the utilization review entity relied 227
349	349	upon in making the adverse determination, and how such rule, 228
350	350	guideline, or protocol applies to the insured's specific medical 229
351	351	circumstance. 230
352	352	(c) Information for the insured and the insured's health 231
353	353	care provider which describes the procedure through which the 232
354	354	insured or health care provider may request a copy of any report 233
355	355	developed by the health care provider performing the review that 234
356	356	led to the adverse determination. 235
357	357	(d) An explanation to the insured and the insured's health 236
358	358	care provider of the appeals process for an adverse 237
359	359	determination. 238
360	360	(12) If a utilization review entity requires prior 239
361	361	authorization of a nonemergency health care service, the 240
362	362	utilization review entity must make an authorization or adverse 241
363	363	determination and notify the insured and the insured's provider 242
364	364	of such service of the decision within 2 business days after 243
365	365	obtaining all necessary information to make the authorization or 244
366	366	adverse determination. For purposes of this subsection, 245
367	367	necessary information includes the results of any face -to-face 246
368	368	clinical evaluation or second opinion that may be required. 247
369	369	(13) A utilization r eview entity shall render an expedited 248
370	370	authorization or adverse determination concerning an emergency 249
371	371	health care service and notify the insured and the insured's 250
372	372
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380	380	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
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382	382
383	383
384	384	provider of such service of the expedited prior authorization or 251
385	385	adverse determination no lat er than 1 business day after 252
386	386	receiving all information needed to complete the review of the 253
387	387	requested urgent health care service. 254
388	388	(14) A utilization review entity may not require prior 255
389	389	authorization for prehospital transportation or for provision of 256
390	390	an emergency health care service. A utilization review entity 257
391	391	may not conduct any utilization review activity, nor render any 258
392	392	adverse determinations, to the extent restricted or prohibited 259
393	393	by an agreement with a health care provider. A utilization 260
394	394	review entity may not perform any utilization review activity, 261
395	395	nor render any adverse determinations, with respect to emergency 262
396	396	health care services beyond verification of the presenting 263
397	397	emergency medical condition. 264
398	398	(15) A utilization review entity may not require p rior 265
399	399	authorization for the provision of medications for opioid use 266
400	400	disorder. As used in this subsection, the term "medications for 267
401	401	opioid use disorder" means the use of medications approved by 268
402	402	the United States Food and Drug Administration (FDA), commonly 269
403	403	in combination with counseling and behavioral therapies, to 270
404	404	provide a comprehensive approach to the treatment of opioid use 271
405	405	disorder. Such FDA-approved medications used to treat opioid 272
406	406	addiction include, but are not limited to, methadone; 273
407	407	buprenorphine, alone or in combination with naloxone; and 274
408	408	extended-release injectable naltrexone. Such types of behavioral 275
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417	417	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
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419	419
420	420
421	421	therapies include, but are not limited to, individual therapy, 276
422	422	group counseling, family therapy, motivational incentives, and 277
423	423	other modalities. 278
424	424	(16) A utilization review entity may not revoke, limit, 279
425	425	condition, or restrict a prior authorization if care is provided 280
426	426	within 45 business days after the date the health care provider 281
427	427	received the prior authorization. A utilization review entity 282
428	428	shall pay the health care provider at the contracted payment 283
429	429	rate for a health care service provided by the health care 284
430	430	provider under a prior authorization unless any of the following 285
431	431	is true: 286
432	432	(a) The health care provider knowingly and materially 287
433	433	misrepresented the health care service in the prior 288
434	434	authorization request with the specific intent to deceive and 289
435	435	obtain an unlawful payment from the utilization review entity. 290
436	436	(b) The health care service was no longer a covered 291
437	437	benefit on the day it was provided, and the utilization review 292
438	438	entity notified the health care provider in writing of this fact 293
439	439	before the health care service was provided. 294
440	440	(c) The authorized service was never performed. 295
441	441	(d) The insured was no longer eligible for health care 296
442	442	coverage on the day the care was provided, and the utilization 297
443	443	review entity notified the health care provider in writing of 298
444	444	this fact before the health care service was provided. 299
445	445	(17) If a utilization review entity required a prior 300
446	446
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454	454	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
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457	457
458	458	authorization for a health care service f or the treatment of a 301
459	459	chronic or long-term care condition, the prior authorization 302
460	460	remains valid for the length of the treatment and the 303
461	461	utilization review entity may not require the insured to obtain 304
462	462	a prior authorization again for the health care service . 305
463	463	(18) A utilization review entity may not impose an 306
464	464	additional prior authorization requirement with respect to a 307
465	465	surgical or otherwise invasive procedure, or any item furnished 308
466	466	as part of such a procedure, if the procedure or item is 309
467	467	furnished during the perioperative period of another procedure 310
468	468	for which prior authorization was granted by the utilization 311
469	469	review entity. 312
470	470	(19) Any change in coverage or approval criteria for a 313
471	471	previously authorized health care service may not affect an 314
472	472	insured who received prior authorization before the effective 315
473	473	date of the change for the remainder of the insured's plan year. 316
474	474	(20) A utilization review entity shall continue to honor a 317
475	475	prior authorization it has granted to an insured when the 318
476	476	insured changes coverage unde r the same insurance company. 319
477	477	(21) Any health care services subject to review are 320
478	478	automatically deemed authorized by the utilization review entity 321
479	479	if it fails to comply with the deadlines and other requirements 322
480	480	specified in this section. 323
481	481	(22) Except as otherwise provided in subsection (16), a 324
482	482	prior authorization constitutes a conclusive determination of 325
483	483
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491	491	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
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493	493
494	494
495	495	the medical necessity of the authorized health care service and 326
496	496	an irrevocable obligation to pay for such authorized health care 327
497	497	service. 328
498	498	(23) The requirements of this section cannot be waived by 329
499	499	contract. Any contractual arrangement or action taken in 330
500	500	conflict with this section, or which purports to waive any 331
501	501	requirement of this section, is void. 332
502	502	(24) This section does not prohibit an agreement with a 333
503	503	health care provider to restrict, limit, prohibit, or substitute 334
504	504	utilization review activity or prior authorization. 335
505	505	Section 2. Section 627.4262, Florida Statutes, is created 336
506	506	to read: 337
507	507	627.4262 Payment adjudication. — 338
508	508	(1) For the purposes of this s ection, the term: 339
509	509	(a) "Downcode" or "downcoding" means the alteration by a 340
510	510	payment adjudicator of the service code to another service code 341
511	511	or the alteration, addition, or removal by a payment adjudicator 342
512	512	of a modifier, when the changed code or modifier i s associated 343
513	513	with a lower payment amount than the service code or modifier 344
514	514	billed by the provider or facility. 345
515	515	(b) "Health plan" means any entity that offers health 346
516	516	insurance coverage, whether through a fully insured plan or a 347
517	517	self-insured plan or fund, including an authorized insurer 348
518	518	offering health insurance as defined in s. 624.603, any entity 349
519	519	that offers a self-insured fund as described in s. 624.462, or 350
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528	528	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
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532	532	group self-insurance funds as described in 624.4621, a health 351
533	533	insurer subject to chapter 627, a ma naged care plan as defined 352
534	534	in s. 409.962, or a health maintenance organization as defined 353
535	535	in s. 641.19. 354
536	536	(c) "Medical record" means the comprehensive collection of 355
537	537	documentation, including clinical notes, diagnostic reports, and 356
538	538	other relevant information , which supports the health care 357
539	539	services provided. 358
540	540	(d) "Participation agreement" means a written contract or 359
541	541	agreement between a health plan and a provider which outlines 360
542	542	the terms and conditions of participation, reimbursement rates, 361
543	543	and other relevant details. 362
544	544	(e) "Payment adjudicator" means a health plan or any 363
545	545	entity that provides, offers to provide, or administers payment 364
546	546	on behalf of a health plan, as well any pharmacy benefit manager 365
547	547	as defined in s. 626.88, and any other individual or entity th at 366
548	548	provides, offers to provide, or administers payment for hospital 367
549	549	services, outpatient services, medical services, prescription 368
550	550	drugs, or other health care services to a person treated by a 369
551	551	health care professional or facility in this state under a 370
552	552	policy, plan, or contract. 371
553	553	(f) "Provider" includes any health care professional, 372
554	554	facility, or entity that submits claims for reimbursement for 373
555	555	covered health care services provided to individuals covered 374
556	556	under a health plan. 375
557	557
558	558	HB 1475 2024
559	559
560	560
561	561
562	562	CODING: Words stricken are deletions; words underlined are additions.
563	563	hb1475-00
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565	565	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
566	566
567	567
568	568
569	569	(2)(a) Payment adjudicators are prohibited from downcoding 376
570	570	a health care service billed by, or on behalf of, a provider, if 377
571	571	the health care service was ordered by a provider in -network 378
572	572	with the applicable health plan, unless such downcoding is 379
573	573	otherwise expressly allowed under the partic ipation agreement 380
574	574	between the health plan and such provider. 381
575	575	(b) If downcoding is expressly allowed under the 382
576	576	participation agreement, the payment adjudicator must first 383
577	577	conduct a review of the associated medical record to ensure the 384
578	578	accuracy of the codi ng change, and then provide the following 385
579	579	information to the provider before making its initial payment or 386
580	580	notice of denial of payment: 387
581	581	1. A statement indicating that the service code or 388
582	582	modifier billed by the provider or facility is going to be 389
583	583	downcoded. 390
584	584	2. An explanation detailing the reasons for downcoding the 391
585	585	claim. This explanation must include a clear description of the 392
586	586	service codes or modifiers that were altered, added, or removed, 393
587	587	if applicable. 394
588	588	3. The payment amount that the payment adjudic ator would 395
589	589	otherwise make if the service code or modifier was not 396
590	590	downcoded. 397
591	591	4. A statement that the provider may contest the 398
592	592	downcoding of the applicable service code or modifier by filing 399
593	593	a contestation with the payment adjudicator with respect to the 400
594	594
595	595	HB 1475 2024
596	596
597	597
598	598
599	599	CODING: Words stricken are deletions; words underlined are additions.
600	600	hb1475-00
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602	602	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
603	603
604	604
605	605
606	606	downcoding within 15 days after receipt of the statements 401
607	607	required under this paragraph. 402
608	608	5. A statement that, by contesting the downcoding of the 403
609	609	applicable service code or modifier, the provider does not waive 404
610	610	any of its legal rights to pursue claims ag ainst the health plan 405
611	611	or payment adjudicator. 406
612	612	(c) A payment adjudicator may not downcode a service code 407
613	613	or modifier for services provided pursuant to orders issued by a 408
614	614	licensed nurse. 409
615	615	(d) Notwithstanding this section, a payment adjudicator 410
616	616	that downcodes a service code or modifier, regardless of whether 411
617	617	such downcoding is contested by the provider, is solely 412
618	618	responsible for any violations of law associated with such 413
619	619	downcoding. 414
620	620	(3)(a) Payment adjudicators shall maintain clear and 415
621	621	accessible downcodin g policies on their official websites. These 416
622	622	policies must include all of the following: 417
623	623	1. An overview of the circumstances under which downcoding 418
624	624	may occur. 419
625	625	2. The process and criteria used for conducting reviews of 420
626	626	downcoded claims, including the ro le of medical record review. 421
627	627	3. Information about the internal mechanisms for ensuring 422
628	628	consistency and accuracy in downcoding practices. 423
629	629	4. Information regarding the processes for contesting the 424
630	630	downcode of a service code with the payment adjudicator. 425
631	631
632	632	HB 1475 2024
633	633
634	634
635	635
636	636	CODING: Words stricken are deletions; words underlined are additions.
637	637	hb1475-00
638	638	Page 18 of 26
639	639	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
640	640
641	641
642	642
643	643	(b) Health plans shall ensure that their downcoding 426
644	644	policies are updated, as needed, to reflect any changes in 427
645	645	regulations, industry standards, or internal procedures. 428
646	646	(4)(a) Payment adjudicators are responsible for ensuring 429
647	647	compliance with this sectio n and shall develop internal 430
648	648	procedures to implement and adhere to the requirements thereof. 431
649	649	(b) The office may investigate and take appropriate 432
650	650	actions in cases of noncompliance with this section. 433
651	651	(5) If any provision of this section or its applicatio n to 434
652	652	any person or circumstances is held invalid, the invalidity does 435
653	653	not affect other provisions or applications of this section 436
654	654	which can be given effect without the invalid provision or 437
655	655	application, and to this end the provisions of this section are 438
656	656	severable. 439
657	657	(6) A provider may bring a private cause of action against 440
658	658	the payment adjudicator for a violation of this section. 441
659	659	Section 3. Present subsections (18) and (19) of section 442
660	660	627.6131, Florida Statutes, are redesignated as subsections (22) 443
661	661	and (23), respectively, new subsections (18) and (19) and 444
662	662	subsections (20) and (21) are added to that section, and 445
663	663	subsections (1) and (2), paragraphs (a) and (c) of subsection 446
664	664	(4), paragraphs (a) and (c) of subsection (5), and subsections 447
665	665	(6), (10), (11), and (13) of that section are amended, to read: 448
666	666	627.6131 Payment of claims. — 449
667	667	(1) The contract must shall include the following 450
668	668
669	669	HB 1475 2024
670	670
671	671
672	672
673	673	CODING: Words stricken are deletions; words underlined are additions.
674	674	hb1475-00
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676	676	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
677	677
678	678
679	679
680	680	provision: "Time of Payment of Claims: After receiving written 451
681	681	proof of loss, the insurer will pay monthly all claims benefits 452
682	682	then due for ...(type of benefit)... . Claims Benefits for any 453
683	683	other loss covered by this policy will be paid as soon as the 454
684	684	insurer receives proper written proof." 455
685	685	(2) As used in this section, the term : 456
686	686	(a) "Claim," for a noninstitutional provider , means a 457
687	687	paper, Centers for Medicare and Medicaid Services (CMS) 1500 458
688	688	form, or its successor, or electronic billing instrument 459
689	689	submitted to the insurer's designated location which that 460
690	690	consists of the ANSI ASC X12N 837P standard HCFA 1500 data set, 461
691	691	or its successor, which that has all mandatory entries for a 462
692	692	physician licensed under chapter 458, chapter 459, chapter 460, 463
693	693	chapter 461, or chapter 463, or psychologists licensed under 464
694	694	chapter 490 or any appropriate billing instrument that has all 465
695	695	mandatory entries for any other noninstitutional provider. For 466
696	696	institutional providers, the term "claim" means a paper or 467
697	697	electronic billing instrument submitted to the insurer's 468
698	698	designated location which that consists of the ANSI ASC X12N 469
699	699	837P standard UB-92 data set, or its successor, with entries 470
700	700	stated as mandatory by the National Uniform Billing Committee. 471
701	701	(b) "Clean claim" means a completed form or completed 472
702	702	electronic billing instrument referenced in paragraph (a) which 473
703	703	contains all of the foll owing information: 474
704	704	1. All information required under the applicable form or 475
705	705
706	706	HB 1475 2024
707	707
708	708
709	709
710	710	CODING: Words stricken are deletions; words underlined are additions.
711	711	hb1475-00
712	712	Page 20 of 26
713	713	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
714	714
715	715
716	716
717	717	electronic billing instrument. 476
718	718	2. Information reasonably required by the insurer to 477
719	719	substantiate the claim, which, except for emergency services and 478
720	720	care as defined in s. 641.4 7, is submitted in advance of the 479
721	721	provision of service. 480
722	722	(c) "Insured ineligibility" means a circumstance in which 481
723	723	an insured is no longer enrolled in the health plan at the time 482
724	724	of receiving the applicable service. 483
725	725	(d) "Overpayment" means a payment that is billed in error, 484
726	726	a duplicate claim, or a payment for a service rendered to a 485
727	727	patient for a service because of insured ineligibility. 486
728	728	(4) For all electronically submitted claims, a health 487
729	729	insurer shall: 488
730	730	(a) Within 24 hours after the beginning of the next 489
731	731	business day after receipt of the claim, provide , to the 490
732	732	electronic source submitting the claim, an electronic 491
733	733	acknowledgment of the receipt of the claim along with its 492
734	734	position as to whether the claim is a clean claim or whether the 493
735	735	claim is missing any information required under the applicable 494
736	736	electronic billing instrument provided in paragraph (2)(a) or 495
737	737	that was reasonably required by the insurer in advance of the 496
738	738	provision of service, other than emergency services and care as 497
739	739	defined in s. 641.47, to substantiate the claim to the 498
740	740	electronic source submitting the claim . 499
741	741	(c)1. Notification of the health insurer's determination 500
742	742
743	743	HB 1475 2024
744	744
745	745
746	746
747	747	CODING: Words stricken are deletions; words underlined are additions.
748	748	hb1475-00
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750	750	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
751	751
752	752
753	753
754	754	of a contested claim must be accompanied by an itemized list of 501
755	755	any additional information required under the applicabl e billing 502
756	756	instrument specified in paragraph (2)(a) or which was reasonably 503
757	757	required by the insurer and the health insurer asserts is still 504
758	758	missing as of the date of such service, other than for emergency 505
759	759	services and care as defined in s. 641.47 or documents the 506
760	760	insurer can reasonably determine are necessary to process the 507
761	761	claim. 508
762	762	2. A provider must submit the additional information or 509
763	763	documentation, as specified on the itemized list, within 35 days 510
764	764	after receipt of the notification unless within such 35 -day 511
765	765	period the provider notifies the insurer of its position that a 512
766	766	clean claim has been submitted . Additional information is 513
767	767	considered submitted on the date it is electronically 514
768	768	transferred or mailed. The health insurer may not request 515
769	769	duplicate documents. 516
770	770	(5) For all nonelectronically submitted claims, a health 517
771	771	insurer shall: 518
772	772	(a) Effective November 1, 2003, Provide to the provider 519
773	773	submitting the claim an acknowledgment of receipt of the claim 520
774	774	along with its position as to whether the claim is a clean claim 521
775	775	or whether the claim is missing any information required under 522
776	776	the applicable paper billing form described in paragraph (2)(a) 523
777	777	which was reasonably required by the insurer to substantiate the 524
778	778	claim in advance of the provision of service, other than f or 525
779	779
780	780	HB 1475 2024
781	781
782	782
783	783
784	784	CODING: Words stricken are deletions; words underlined are additions.
785	785	hb1475-00
786	786	Page 22 of 26
787	787	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
788	788
789	789
790	790
791	791	emergency services and care as defined in s. 641.47, within 15 526
792	792	days after receipt of the claim to the provider or provide a 527
793	793	provider within 15 days after receipt with electronic access to 528
794	794	the status of a submitted claim. 529
795	795	(c)1. Notification of the heal th insurer's determination 530
796	796	of a contested claim must be accompanied by an itemized list of 531
797	797	any additional information required under the applicable billing 532
798	798	instrument described in paragraph (2)(a) or which was reasonably 533
799	799	required by the insurer to substant iate the claim in advance of 534
800	800	the provision of service, other than for emergency services and 535
801	801	care as defined in s. 641.47, which the health insurer asserts 536
802	802	is still missing as of the date of such service or documents the 537
803	803	insurer can reasonably determine ar e necessary to process the 538
804	804	claim. 539
805	805	2. A provider must submit the additional information or 540
806	806	documentation, as specified on the itemized list, within 35 days 541
807	807	after receipt of the notification unless, within such 35 -day 542
808	808	period, the provider notifies the insu rer of its position that a 543
809	809	clean claim has been submitted . Additional Information is 544
810	810	considered submitted on the date it is electronically 545
811	811	transferred or mailed. The health insurer may not request 546
812	812	duplicate documents. 547
813	813	(6) If a health insurer determines t hat it has made an 548
814	814	overpayment to a provider for services rendered to an insured, 549
815	815	the health insurer must make a claim for such overpayment to the 550
816	816
817	817	HB 1475 2024
818	818
819	819
820	820
821	821	CODING: Words stricken are deletions; words underlined are additions.
822	822	hb1475-00
823	823	Page 23 of 26
824	824	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
825	825
826	826
827	827
828	828	provider's designated location. A health insurer that makes a 551
829	829	claim for overpayment to a provider under this section shall 552
830	830	give the provider a written or electronic statement specifying 553
831	831	the basis for the retrospective retroactive denial or payment 554
832	832	adjustment. The insurer must identify the claim or claims, or 555
833	833	overpayment claim portion thereof, for which a claim fo r 556
834	834	overpayment is submitted. 557
835	835	(a) If an overpayment determination is the result of 558
836	836	retrospective retroactive review or retrospective audit of 559
837	837	coverage decisions or payment levels not related to fraud , a 560
838	838	health insurer must shall adhere to all of the following 561
839	839	procedures: 562
840	840	1. All claims for overpayment must be submitted to a 563
841	841	provider within 30 months after the health insurer's payment of 564
842	842	the claim. A provider must pay, deny, or contest the health 565
843	843	insurer's claim for overpayment within 40 days after the rece ipt 566
844	844	of the claim. All contested claims for overpayment must be paid 567
845	845	or denied within 120 days after receipt of the claim. Failure to 568
846	846	pay or deny overpayment and claim within 140 days after receipt 569
847	847	creates an uncontestable obligation to pay the claim. 570
848	848	2. A provider that denies or contests a health insurer's 571
849	849	claim for overpayment or any portion of a claim shall notify the 572
850	850	health insurer, in writing, within 35 days after the provider 573
851	851	receives the claim that the claim for overpayment is contested 574
852	852	or denied. The notice that the claim for overpayment is denied 575
853	853
854	854	HB 1475 2024
855	855
856	856
857	857
858	858	CODING: Words stricken are deletions; words underlined are additions.
859	859	hb1475-00
860	860	Page 24 of 26
861	861	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
862	862
863	863
864	864
865	865	or contested must identify the contested portion of the claim 576
866	866	and the specific reason for contesting or denying the claim and, 577
867	867	if contested, must include a request for additional information. 578
868	868	If the health insurer submits additional information, the health 579
869	869	insurer must, within 35 days after receipt of the request, mail 580
870	870	or electronically transfer the information to the provider. The 581
871	871	provider shall pay or deny the claim for overpayment within 45 582
872	872	days after receipt of the information. The notice is considered 583
873	873	made on the date the notice is mailed or electronically 584
874	874	transferred by the provider. 585
875	875	3. The health insurer may not reduce payment to the 586
876	876	provider for other services unless the provider agrees to the 587
877	877	reduction in writing or fails to respond to the health insurer's 588
878	878	overpayment claim as required by this paragraph. 589
879	879	4. Payment of an overpayment claim is considered made on 590
880	880	the date the payment was mailed or electronically transferred. 591
881	881	An overdue payment of a claim bears simple interest at the rate 592
882	882	of 12 percent per year. Interest on an overdue payment for a 593
883	883	claim for an overpayment begins to accrue when the claim should 594
884	884	have been paid, denied, or contested. 595
885	885	(b) A claim for overpayment shall not be permitted beyond 596
886	886	30 months after the health insurer's payment of a claim, except 597
887	887	that claims for overpayment may be sought beyond that time from 598
888	888	providers convicted of fraud pursuant to s. 817.234. 599
889	889	(10) The provisions of this section may not be waived, 600
890	890
891	891	HB 1475 2024
892	892
893	893
894	894
895	895	CODING: Words stricken are deletions; words underlined are additions.
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898	898	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
899	899
900	900
901	901
902	902	voided, or nullified by contract. 601
903	903	(10)(11) A health insurer may not retrospectively 602
904	904	retroactively deny a claim because of insured ineligibility more 603
905	905	than 90 days 1 year after the date of payment of the claim. 604
906	906	(12)(13) Upon written notification by an insured, an 605
907	907	insurer shall investigate any claim of improper billing of the 606
908	908	insured by a physician, hospital, or other health care provider 607
909	909	for a health care service alleged not to have been received . The 608
910	910	insurer shall determine if the insured received such service was 609
911	911	properly billed for only those procedures and services that the 610
912	912	insured actually received . If the insurer determines that the 611
913	913	insured did not receive the service has been improperly billed , 612
914	914	the insurer must shall notify the insured and the provider of 613
915	915	its findings and shall reduce the amount of payment to the 614
916	916	provider by the amount charged for the service that was not 615
917	917	received determined to be improperly billed. If a reduction is 616
918	918	made due to such notification b y the insured, the insurer shall 617
919	919	pay to the insured 20 percent of the amount of the reduction up 618
920	920	to $500. 619
921	921	(18) This section may not be interpreted to limit, 620
922	922	restrict, or negatively impact any legal claim by a provider or 621
923	923	insurer for breach of contract, s tatutory or regulatory 622
924	924	violation, or under a common law cause of action, or shorten or 623
925	925	otherwise negatively impact the statute of limitations timeframe 624
926	926	for bringing any such legal claim. 625
927	927
928	928	HB 1475 2024
929	929
930	930
931	931
932	932	CODING: Words stricken are deletions; words underlined are additions.
933	933	hb1475-00
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935	935	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
936	936
937	937
938	938
939	939	(19) A health insurer may not request information from a 626
940	940	contracted or noncontracted provider which does not apply to the 627
941	941	medical condition at issue for the purposes of making a 628
942	942	determination of a clean claim. 629
943	943	(20) A health insurer may not request a contracted or 630
944	944	noncontracted provider to resubmit claim information that the 631
945	945	contracted or noncontracted provider can document it has already 632
946	946	provided to the health insurer. 633
947	947	(21) Notwithstanding any law to the contrary, an insurer 634
948	948	may not require any information from a provider before the 635
949	949	provision of emergency services and care as defined in s. 641.47 636
950	950	as a condition of payment of a claim, as a basis for denying or 637
951	951	reducing payment of a claim, or in contesting whether the claim 638
952	952	is a clean claim. 639
953	953	Section 4. This act shall take effect July 1, 2024. 640