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