Florida Senate - 2024 SB 1574 By Senator Jones 34-01577-24 20241574__ 1 A bill to be entitled 2 An act relating to health care services; amending s. 3 627.42392, F.S.; defining terms; revising the 4 definitions of the terms health insurer as 5 utilization review entity; requiring utilization 6 review entities to establish and offer a prior 7 authorization process for accepting electronic prior 8 authorization requests by a specified date; specifying 9 a requirement for the process; specifying additional 10 requirements and procedures for, and restrictions and 11 limitations on, utilization review entities relating 12 to prior authorization for covered health care 13 benefits; defining the term medications for opioid 14 use disorder; providing construction; creating s. 15 627.4262, F.S.; defining terms; prohibiting payment 16 adjudicators from downcoding health care services 17 under certain circumstances; requiring payment 18 adjudicators to provide certain information prior to 19 making their initial payment or notice of denial of 20 payment; prohibiting downcoding by payment 21 adjudicators for certain orders; providing that a 22 payment adjudicator is solely responsible for certain 23 violations of law; requiring payment adjudicators to 24 maintain downcoding policies on their websites; 25 specifying the requirements of such policies; 26 providing that payment adjudicators are responsible 27 for compliance with certain provisions; requiring 28 payment adjudicators to develop certain internal 29 procedures; authorizing the Office of Insurance 30 Regulation to investigate and take appropriate actions 31 under certain circumstances; providing severability; 32 authorizing a provider to bring a private cause of 33 action under certain circumstances; amending s. 34 627.6131, F.S.; revising the requirements of insurer 35 contracts; revising the definition of the term 36 claim; defining terms; revising the requirements for 37 health insurers submitting claims electronically and 38 nonelectronically; making technical changes; deleting 39 the prohibition against waiving, voiding, or 40 nullifying certain provisions by contract; prohibiting 41 a health insurer from retrospectively denying a claim 42 under certain circumstances; revising procedures for 43 investigation of claims of improper billing; providing 44 construction; prohibiting health care insurers from 45 requesting certain information or resubmission of 46 claims under certain circumstances; prohibiting an 47 insurer from requiring information from a provider 48 before the provision of emergency services and care; 49 providing an effective date. 50 51 Be It Enacted by the Legislature of the State of Florida: 52 53 Section 1.Section 627.42392, Florida Statutes, is amended 54 to read: 55 627.42392Prior authorization. 56 (1)As used in this section, the term: 57 (a)Adverse determination means a decision by a health 58 insurer or utilization review entity to deny, reduce, or 59 terminate health care services furnished or proposed to be 60 furnished to an insured. The term does not include a decision to 61 deny, reduce, or terminate services that were determined to be 62 duplicate bills or that are confirmed with the provider to have 63 been billed in error. 64 (b)Electronic prior authorization process does not 65 include transmissions through a facsimile machine. 66 (c)Emergency health care services has the same meaning 67 as emergency services and care as defined in s. 395.002. 68 (d)Prior authorization means the process by which health 69 insurers, third-party payors, or utilization review entities 70 determine the medical necessity of nonemergency health care 71 services before the rendering of such services by the provider. 72 Such prior authorization is authorized by the applicable 73 agreement with the health care provider or such prior 74 authorization is otherwise obtained by a provider that does not 75 have such an agreement. The term also includes a health 76 insurers or utilization review entitys requirement, if such 77 requirement is permitted by the applicable agreement with a 78 health care provider or otherwise permitted by a health care 79 provider that does not have such an agreement, that a patient or 80 health care provider notify the health insurer or utilization 81 review entity before the provision of a nonemergency health care 82 service. 83 (e)Urgent health care service means a health care 84 service to treat a medical condition that, if the timeframe for 85 making a nonexpedited prior authorization were to be applied, 86 could, in the opinion of a physician with knowledge of the 87 patients medical condition: 88 1.Seriously jeopardize the life or health of the patient 89 or the ability of the patient to regain maximum function; or 90 2.Subject the patient to severe pain that cannot be 91 adequately managed without the care, treatment, or prescription 92 drug that is the subject of the prior authorization request. 93 (f)Utilization review activity means any action taken 94 prospective to, concurrent with, or retrospective to the 95 provision of nonemergency health care services to determine 96 whether a claim is paid or is subject to an adverse 97 determination. Utilization review activity is not allowed to the 98 extent restricted or prohibited by an agreement with a health 99 care provider or, other than to verify a presenting emergency 100 medical condition, for emergency health care services. For 101 purposes of this paragraph, the term a presenting emergency 102 medical condition means a medical condition manifesting itself 103 by acute symptoms of sufficient severity, including severe pain, 104 such that a prudent layperson who possesses an average knowledge 105 of health and medicine could reasonably expect the absence of 106 immediate medical attention to result in a condition or 107 situation described in s. 395.002(8). 108 (g)Utilization review entity health insurer means an 109 authorized insurer offering health insurance as defined in s. 110 624.603, a managed care plan as defined in s. 409.962(10), or a 111 health maintenance organization as defined in s. 641.19(12), a 112 pharmacy benefit manager as defined in s. 624.490, or any other 113 individual or entity that provides, offers to provide, or 114 administers payment for hospital services, outpatient services, 115 medical services, prescription drugs, or other health care 116 services to a person treated by a health care professional or 117 facility in this state under a policy, plan, or contract. 118 (2)Beginning January 1, 2025, a utilization review entity 119 shall establish and offer a secure, interactive, online, 120 electronic prior authorization process for accepting electronic 121 prior authorization requests. The process must allow a person 122 seeking prior authorization the ability to upload documentation 123 if such documentation is required by the utilization review 124 entity to make a determination on the prior authorization 125 request. 126 (3)Notwithstanding any other provision of law, effective 127 January 1, 2017, or 6 six (6) months after the effective date of 128 the rule adopting the prior authorization form, whichever is 129 later, a utilization review entity that health insurer, or a 130 pharmacy benefits manager on behalf of the health insurer, which 131 does not provide an electronic prior authorization process for 132 use by its contracted providers, shall use only use the prior 133 authorization form that has been approved by the Financial 134 Services commission for granting a prior authorization for a 135 medical procedure, course of treatment, or prescription drug 136 benefit. Such form may not exceed two pages in length, excluding 137 any instructions or guiding documentation, and must include all 138 clinical documentation necessary for the utilization review 139 entity health insurer to make a decision. At a minimum, the form 140 must include: 141 (a)(1)Sufficient patient information to identify the 142 member, date of birth, full name, and health plan ID number; 143 (b)(2)The providers provider name, address, and phone 144 number; 145 (c)(3)The medical procedure, course of treatment, or 146 prescription drug benefit being requested, including the medical 147 reason therefor, and all services tried and failed; 148 (d)(4)Any laboratory documentation required; and 149 (e)(5)An attestation that all information provided is true 150 and accurate. 151 (4)(3)The Financial Services commission, in consultation 152 with the Agency for Health Care Administration, shall adopt by 153 rule guidelines for all prior authorization forms which ensure 154 the general uniformity of such forms. 155 (5)(4)Electronic prior authorization approvals do not 156 preclude benefit verification or medical review by the 157 utilization review entity insurer under either the medical or 158 pharmacy benefits. 159 (6)A utilization review entitys prior authorization 160 process may not require information that is not needed to make a 161 determination or facilitate a determination of medical necessity 162 of the requested medical procedure, course of treatment, or 163 prescription drug benefit. 164 (7)A utilization review entity shall disclose all of its 165 prior authorization requirements and restrictions, including any 166 written clinical criteria, in a publicly accessible manner on 167 its website. Such information must be explained in detail and in 168 clear and ordinary terms. 169 (8)A utilization review entity may not implement any new 170 requirement or restriction or make changes to existing 171 requirements for or restrictions on obtaining prior 172 authorization unless both of the following conditions are met: 173 (a)The changes have been available on a publicly 174 accessible website for at least 60 days before they are 175 implemented. 176 (b)Insureds and health care providers affected by the new 177 requirements and restrictions or by the changes to the 178 requirements and restrictions are provided with a written notice 179 of the changes at least 60 days before they are implemented. 180 Such notice must be delivered electronically or by other means 181 as agreed to by the insured or the health care provider. 182 (9)A utilization review entity shall make available on its 183 website, in a readily accessible format, data regarding prior 184 authorization approvals and denials, which must include all of 185 the following: 186 (a)All items and services requiring prior authorization. 187 (b)The percentage, in aggregate, of prior authorization 188 requests approved. 189 (c)The percentage, in aggregate, of prior authorization 190 requests denied. 191 (d)The percentage of prior authorization requests approved 192 after appeal. 193 (e)The percentage of prior authorization requests in which 194 the timeframe for review was extended and the prior 195 authorization request was approved. 196 (f)The percentage of expedited prior authorization 197 requests approved. 198 (g)The average and median time between submission of a 199 request for prior authorization and a determination of the 200 outcome. 201 (h)The average and median time between submission of a 202 request for an expedited prior authorization and a determination 203 of the outcome. 204 205 This subsection does not apply to the expansion of health care 206 services coverage. 207 (10)A utilization review entity shall ensure that all 208 adverse determinations are made by a physician licensed pursuant 209 to chapter 458 or chapter 459. All of the following requirements 210 apply to such physicians: 211 (a)The physician must possess a current and valid 212 nonrestricted license to practice medicine in this state. 213 (b)The physician must be of the same specialty as the 214 physician who typically manages the medical condition or disease 215 or who provides the health care service that is the subject of 216 the request. 217 (c)The physician must have experience treating patients 218 with the medical condition or disease for which the health care 219 service is being requested. 220 (11)Notice of an adverse determination must be provided by 221 e-mail to the health care provider that initiated the prior 222 authorization. The notice must include all of the following: 223 (a)The name, title, e-mail address, and telephone number 224 of the physician responsible for making the adverse 225 determination. 226 (b)Any written clinical criteria and any internal rule, 227 guideline, or protocol that the utilization review entity relied 228 upon in making the adverse determination, and how such rule, 229 guideline, or protocol applies to the insureds specific medical 230 circumstance. 231 (c)Information for the insured and the insureds health 232 care provider which describes the procedure through which the 233 insured or health care provider may request a copy of any report 234 developed by the health care provider performing the review that 235 led to the adverse determination. 236 (d)An explanation to the insured and the insureds health 237 care provider of the appeals process for an adverse 238 determination. 239 (12)If a utilization review entity requires prior 240 authorization of a nonemergency health care service, the 241 utilization review entity must make an authorization or adverse 242 determination and notify the insured and the insureds provider 243 of such service of the decision within 2 business days after 244 obtaining all necessary information to make the authorization or 245 adverse determination. For purposes of this subsection, 246 necessary information includes the results of any face-to-face 247 clinical evaluation or second opinion that may be required. 248 (13)A utilization review entity shall render an expedited 249 authorization or adverse determination concerning an emergency 250 health care service and notify the insured and the insureds 251 provider of such service of the expedited prior authorization or 252 adverse determination no later than 1 business day after 253 receiving all information needed to complete the review of the 254 requested urgent health care service. 255 (14)A utilization review entity may not require prior 256 authorization for prehospital transportation or for provision of 257 an emergency health care service. A utilization review entity 258 may not conduct any utilization review activity, nor render any 259 adverse determinations, to the extent restricted or prohibited 260 by an agreement with a health care provider. A utilization 261 review entity may not perform any utilization review activity, 262 nor render any adverse determinations, with respect to emergency 263 health care services beyond verification of the presenting 264 emergency medical condition. 265 (15)A utilization review entity may not require prior 266 authorization for the provision of medications for opioid use 267 disorder. As used in this subsection, the term medications for 268 opioid use disorder means the use of medications approved by 269 the United States Food and Drug Administration (FDA), commonly 270 in combination with counseling and behavioral therapies, to 271 provide a comprehensive approach to the treatment of opioid use 272 disorder. Such FDA-approved medications used to treat opioid 273 addiction include, but are not limited to, methadone; 274 buprenorphine, alone or in combination with naloxone; and 275 extended-release injectable naltrexone. Such types of behavioral 276 therapies include, but are not limited to, individual therapy, 277 group counseling, family therapy, motivational incentives, and 278 other modalities. 279 (16)A utilization review entity may not revoke, limit, 280 condition, or restrict a prior authorization if care is provided 281 within 45 business days after the date the health care provider 282 received the prior authorization. A utilization review entity 283 shall pay the health care provider at the contracted payment 284 rate for a health care service provided by the health care 285 provider under a prior authorization unless any of the following 286 is true: 287 (a)The health care provider knowingly and materially 288 misrepresented the health care service in the prior 289 authorization request with the specific intent to deceive and 290 obtain an unlawful payment from the utilization review entity. 291 (b)The health care service was no longer a covered benefit 292 on the day it was provided, and the utilization review entity 293 notified the health care provider in writing of this fact before 294 the health care service was provided. 295 (c)The authorized service was never performed. 296 (d)The insured was no longer eligible for health care 297 coverage on the day the care was provided, and the utilization 298 review entity notified the health care provider in writing of 299 this fact before the health care service was provided. 300 (17)If a utilization review entity required a prior 301 authorization for a health care service for the treatment of a 302 chronic or long-term care condition, the prior authorization 303 remains valid for the length of the treatment and the 304 utilization review entity may not require the insured to obtain 305 a prior authorization again for the health care service. 306 (18)A utilization review entity may not impose an 307 additional prior authorization requirement with respect to a 308 surgical or otherwise invasive procedure, or any item furnished 309 as part of such a procedure, if the procedure or item is 310 furnished during the perioperative period of another procedure 311 for which prior authorization was granted by the utilization 312 review entity. 313 (19)Any change in coverage or approval criteria for a 314 previously authorized health care service may not affect an 315 insured who received prior authorization before the effective 316 date of the change for the remainder of the insureds plan year. 317 (20)A utilization review entity shall continue to honor a 318 prior authorization it has granted to an insured when the 319 insured changes coverage under the same insurance company. 320 (21)Any health care services subject to review are 321 automatically deemed authorized by the utilization review entity 322 if it fails to comply with the deadlines and other requirements 323 specified in this section. 324 (22)Except as otherwise provided in subsection (16), a 325 prior authorization constitutes a conclusive determination of 326 the medical necessity of the authorized health care service and 327 an irrevocable obligation to pay for such authorized health care 328 service. 329 (23) The requirements of this section cannot be waived by 330 contract. Any contractual arrangement or action taken in 331 conflict with this section, or which purports to waive any 332 requirement of this section, is void. 333 (24)This section does not prohibit an agreement with a 334 health care provider to restrict, limit, prohibit, or substitute 335 utilization review activity or prior authorization. 336 Section 2.Section 627.4262, Florida Statutes, is created 337 to read: 338 627.4262Payment adjudication. 339 (1)For the purposes of this section, the term: 340 (a)Downcode or downcoding means the alteration by a 341 payment adjudicator of the service code to another service code 342 or the alteration, addition, or removal by a payment adjudicator 343 of a modifier, when the changed code or modifier is associated 344 with a lower payment amount than the service code or modifier 345 billed by the provider or facility. 346 (b)Health plan means any entity that offers health 347 insurance coverage, whether through a fully insured plan or a 348 self-insured plan or fund, including an authorized insurer 349 offering health insurance as defined in s. 624.603, any entity 350 that offers a self-insured fund as described in s. 624.462, or 351 group self-insurance funds as described in 624.4621, a health 352 insurer subject to chapter 627, a managed care plan as defined 353 in s. 409.962, or a health maintenance organization as defined 354 in s. 641.19. 355 (c)Medical record means the comprehensive collection of 356 documentation, including clinical notes, diagnostic reports, and 357 other relevant information, which supports the health care 358 services provided. 359 (d)Participation agreement means a written contract or 360 agreement between a health plan and a provider which outlines 361 the terms and conditions of participation, reimbursement rates, 362 and other relevant details. 363 (e)Payment adjudicator means a health plan or any entity 364 that provides, offers to provide, or administers payment on 365 behalf of a health plan, as well any pharmacy benefit manager as 366 defined in s. 626.88, and any other individual or entity that 367 provides, offers to provide, or administers payment for hospital 368 services, outpatient services, medical services, prescription 369 drugs, or other health care services to a person treated by a 370 health care professional or facility in this state under a 371 policy, plan, or contract. 372 (f)Provider includes any health care professional, 373 facility, or entity that submits claims for reimbursement for 374 covered health care services provided to individuals covered 375 under a health plan. 376 (2)(a)Payment adjudicators are prohibited from downcoding 377 a health care service billed by, or on behalf of, a provider, if 378 the health care service was ordered by a provider in-network 379 with the applicable health plan, unless such downcoding is 380 otherwise expressly allowed under the participation agreement 381 between the health plan and such provider. 382 (b)If downcoding is expressly allowed under the 383 participation agreement, the payment adjudicator must first 384 conduct a review of the associated medical record to ensure the 385 accuracy of the coding change, and then provide the following 386 information to the provider before making its initial payment or 387 notice of denial of payment: 388 1.A statement indicating that the service code or modifier 389 billed by the provider or facility is going to be 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 adjudicator would 395 otherwise make if the service code or modifier was not 396 downcoded. 397 4.A statement that the provider may contest the downcoding 398 of the applicable service code or modifier by filing a 399 contestation with the payment adjudicator with respect to the 400 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 against 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 downcoding 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 role 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 (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 section and shall develop internal 430 procedures to implement and adhere to the requirements thereof. 431 (b)The office may investigate and take appropriate actions 432 in cases of noncompliance with this section. 433 (5)If any provision of this section or its application 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: 448 627.6131Payment of claims. 449 (1)The contract must shall include the following 450 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 insurers 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 insurers 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 following information: 474 1.All information required under the applicable form or 475 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. 641.47, 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 insurers determination of 500 a contested claim must be accompanied by an itemized list of any 501 additional information required under the applicable 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 for 525 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 health insurers determination of 530 a contested claim must be accompanied by an itemized list of any 531 additional information required under the applicable billing 532 instrument described in paragraph (2)(a) or which was reasonably 533 required by the insurer to substantiate 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 are 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 insurer 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 that 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 providers 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 for 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 insurers payment of 564 the claim. A provider must pay, deny, or contest the health 565 insurers claim for overpayment within 40 days after the receipt 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 insurers 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 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 insurers 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 insurers 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 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 by 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, statutory 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 (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.