Insurance Claims Payments to Health Care Providers

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A bill to be entitled 1
An act relating to insurance claims payments to health 2
care providers; creating s. 627.4193, F.S.; providing 3
definitions; prohibiting payment adjudicators from 4
downcoding health care services under certain 5
circumstances; providing exceptions; providing 6
requirements for such exceptions; requiring health 7
insurers to ensure that their downcoding policies are 8
updated and to ensure compliance with specified 9
provisions on downcoding; authorizing investigations 10
and actions against noncompliance; providing certain 11
presumption in favor of physicians' determination 12
regarding patients' diagnoses and service orders; 13
providing calculations of interests on health 14
insurers' nonpayment and underpayment due to 15
downcoding; providing causes of action for health care 16
providers; amending s. 627.42392, F.S.; providing and 17
revising definitions; requiring utilization review 18
entities to establish electronic prior authorizations 19
to accept prior authorization requests; providing 20
requirements for such entities and for prior 21
authorization processes; prohibiting such entities 22
from implementing new requirements, restrictions, and 23
changes; providing exceptions; providing reporting 24
requirements; requiring the Office of Insurance 25

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Regulation to publish a report based on such entities' 26
reports; providing requirements for adverse 27
determinations made by such entities on health care 28
providers' claims; providing a timeframe for such 29
entities' determination on claims; prohibiting prior 30
authorization requirements under certain 31
circumstances; prohibiting prior authorization 32
revocations, limits, conditions, and restrictions 33
under certain circumstances; providing exceptions; 34
providing validity timeframe of prior authorizations 35
under certain circumstances; providing construction; 36
amending ss. 627.6131 and 641.3155, F.S.; providing 37
and revising definitions; revising requirements and 38
timeframes for responses from health insurers and 39
health maintenance organizations, respectively, to 40
submitted claims; revising interests on overdue 41
payments of claims; authorizing health care providers 42
to refuse to participate in internal dispute 43
resolution processes under certain circumstances; 44
prohibiting health insurers and health maintenance 45
organizations, respectively, from retrospectively, 46
rather than retroactively, denying claims because of 47
insured and enrollee ineligibility beyond a specified 48
timeframe; revising such timeframe; revising 49
applicability; providing construction; prohibiting 50

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health insurers and health maintenance organizations, 51
respectively, from requesting or requiring certain 52
information from health care providers under certain 53
circumstances; providing causes of action for health 54
care providers under certain circumstances; amending 55
s. 395.1065, F.S.; conforming cross-references; 56
providing an effective date. 57
58
Be It Enacted by the Legislature of the State of Florida: 59
60
Section 1. Section 627.4193, Florida Statutes, is created 61
to read: 62
627.4193 Restrictions on health insurance reimbursement 63
downcoding.— 64
(1) As used in this section, the term: 65
(a) "Downcode" or "downcoding" means the alteration by a 66
payment adjudicator of a service code to another service code or 67
the alteration, addition, or removal by a payment adjudicator of 68
a modifier, when the changed code or modifier is associated with 69
a lower payment amount than the service code or modifier billed 70
by the provider or facility. 71
(b) "Health insurer" means any entity that offers health 72
insurance coverage, whether through a fully insured plan or 73
self-insured plan or fund, including, as applicable: 74
1. An authorized health insurer offering health insurance 75

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as defined in s. 624.603, as well as any entity that offers a 76
commercial self-insurance fund as defined in s. 624.462(2) or 77
group self-insurance fund as described in s. 624.4621. 78
2. A health insurer that is subject to any of the 79
provisions of this chapter, as well as any entity that offers a 80
self-insurance plan or a group self-insurance plan. 81
3. A managed care plan as defined in s. 409.962. 82
4. A health maintenance organization as defined in s. 83
641.19. 84
(c) "Medical record" means the comprehensive collection of 85
documentation, including clinical notes, diagnostic reports, and 86
other relevant information, which supports the health care 87
services provided. 88
(d) "Participation agreement" means a written contract or 89
agreement between a health insurer and a provider which outlines 90
the terms and conditions of participation, reimbursement rates, 91
and other relevant details. 92
(e) "Payment adjudicator" means a health insurer or any 93
entity that provides, offers to provide, or administers payment 94
on behalf of a health insurer, as well any pharmacy benefit 95
manager as defined in s. 624.490(1), and any other individual or 96
entity that provides, offers to provide, or administers payment 97
for hospital services, outpatient services, medical services, 98
prescription drugs, or other health care services, to a person 99
treated by a health care professional or facility in this state 100

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under a policy, plan, or contract. 101
(f) "Provider" means any health care professional, 102
facility, or entity that submits claims for reimbursement for 103
covered health care services. 104
(2) Payment adjudicators are prohibited from downcoding a 105
health care service billed by, or on behalf of, a provider, if 106
the health care service was ordered by a provider that is in-107
network with the applicable health insurer, unless such 108
downcoding is otherwise expressly permitted under the 109
participation agreement between the health insurer and the 110
provider. 111
(3) If downcoding is expressly permitted under the 112
participation agreement, the payment adjudicator must provide 113
the following information to the provider before making its 114
initial payment or notice of denial of payment: 115
(a) A statement indicating that the service code or 116
modifier billed by the provider or facility is going to be 117
downcoded. 118
(b) An explanation detailing the reasons for downcoding 119
the claim. This explanation must include a clear description of 120
the service codes or modifiers that were altered, added, or 121
removed, if applicable. 122
(c) The payment amount that the payment adjudicator would 123
otherwise make if the service code or modifier is not downcoded. 124
(d) A statement that the provider may contest the 125

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downcoding of the applicable service code or modifier by filing 126
a contestation with the payment adjudicator with respect to the 127
downcoding within 15 days after receipt of the notice of 128
downcoding. 129
(e) A statement that by contesting the downcoding of the 130
applicable service code or modifier, the provider does not waive 131
any of its legal rights and claims against the health insurer or 132
payment adjudicator to the fullest extent permissible under law. 133
(4) Even if the participation agreement expressly permits 134
downcoding, a payment adjudicator is prohibited from downcoding 135
a service without first conducting a review of the associated 136
medical record to ensure the accuracy of the coding change. 137
(5) A payment adjudicator is prohibited from downcoding 138
for orders by a licensed nurse. 139
(6) Notwithstanding any provision in this section, a 140
payment adjudicator that proceeds to downcode a service code or 141
modifier, regardless of whether such downcoding is contested by 142
the provider, is solely responsible for any violations of law 143
associated with such downcoding. 144
(7) Payment adjudicators are required to maintain clear 145
and accessible downcoding policies on their official website. 146
These policies must include: 147
(a) An overview of the circumstances under which 148
downcoding may occur. 149
(b) The process and criteria used for conducting reviews 150

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of downcoded claims, including the role of medical record 151
review. 152
(c) Information about the internal mechanisms for ensuring 153
consistency and accuracy in downcoding practices. 154
(d) Information regarding the processes for contesting 155
with the payment adjudicator the downcoding of a service code, 156
which processes must offer appeal rights for the provider and 157
the patient, and peer review by a licensed physician before the 158
downcoding. 159
(8) Health insurers shall ensure that their downcoding 160
policies are updated as needed to reflect any changes in 161
regulations, industry standards, or internal procedures. 162
(9) Health insurers shall ensure compliance with this 163
section and shall develop internal procedures to implement and 164
adhere to the requirements outlined in this section. 165
(10) Regulatory authorities, including, but not limited 166
to, the Office of Insurance Regulation, may investigate and take 167
appropriate actions in cases of noncompliance with this section. 168
(11) When a particular health care service is ordered by a 169
licensed physician, there shall be a presumption that the 170
physician determination regarding the diagnosis of the patient 171
and service order by the physician is correct and sufficient, 172
absent a coding error which the health insurer must first verify 173
with the physician before downcoding for such error. 174
(12) If an applicable court, arbitration tribunal, or 175

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other binding legal process determines that a claim was subject 176
to an inappropriate or impermissible downcoding, whether in 177
breach of contract, statute, common law, or otherwise, such that 178
nonpayment or underpayment of the original claim has occurred, 179
then in accordance with s. 627.6131, interest shall be 180
calculated upon the full total amount that should have been paid 181
on the claim as of the applicable time period for payment 182
specified in s. 627.6131. 183
(13) In the instance of a violation of this section, a 184
provider shall have a private cause of action to proceed against 185
the health insurer or payment adjudicator in the applicable 186
tribunal for the violation. 187
Section 2. Section 627.42392, Florida Statutes, is amended 188
to read: 189
627.42392 Prior authorization.— 190
(1) As used in this section, the term: 191
(a) "Adverse determination" means a decision by a health 192
insurer or utilization review entity that the health care 193
services rendered, or proposed to be rendered, to a patient are 194
denied, reduced, or terminated. The term does not include a 195
decision to deny, reduce, or terminate services that are 196
determined to have been billed in duplicate bills or that are 197
confirmed with the provider to have been billed in error. 198
(b) "Electronic prior authorization process" does not 199
include transmissions through a facsimile machine. 200

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(c) "Emergency health care service" means medical 201
screening, examination, and evaluation by a physician, or, to 202
the extent permitted by applicable law, by other appropriate 203
personnel under the supervision of a physician, to determine if 204
an emergency medical condition exists and, if it does, the care, 205
treatment, or surgery by a physician necessary to relieve or 206
eliminate the emergency medical condition, within the service 207
capability of the facility. 208
(d) "Emergency medical condition" means a medical 209
condition manifesting itself by acute symptoms of sufficient 210
severity, including severe pain, such that a prudent layperson 211
who possesses an average knowledge of health and medicine could 212
reasonably expect the absence of immediate medical attention to 213
result in any of the conditions listed in s. 395.002(8). 214
(e) "Health insurer" means any entity that offers health 215
insurance coverage, whether through a fully insured plan or 216
self-insured plan or fund, including, as applicable: 217
1. An authorized health insurer offering health insurance 218
as defined in s. 624.603, as well as any entity that offers a 219
commercial self-insurance fund as defined in s. 624.462(2) or a 220
group self-insurance fund as described in s. 624.4621. 221
2. A health insurer that is subject to any of the 222
provisions of this chapter, as well as any entity that offers a 223
self-insurance plan or a group self-insurance plan. 224
3. A managed care plan as defined in s. 409.962. 225

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4. A health maintenance organization as defined in s. 226
641.19. 227
(f) "Prior authorization" means the process by which 228
utilization review entities determine the medical necessity or 229
medical appropriateness of otherwise covered health care 230
services before the rendering of such health care services. The 231
term also includes any requirement by a health insurer or 232
utilization review entity that an enrollee or health care 233
provider notify the health insurer or utilization review entity 234
before the provision of a health care service. 235
(g) "Urgent health care service" means a health care 236
service that, if the timeframe for making a nonexpedited prior 237
authorization is applied, could, in the opinion of a physician 238
with knowledge of the patient's medical condition: 239
1. Seriously jeopardize the life or health of the patient 240
or the ability of the patient to regain maximum function; or 241
2. Subject the patient to severe pain that cannot be 242
adequately managed without the care, treatment, or prescription 243
drugs that are the subject of the prior authorization request. 244
(h) "Utilization review activity" means any activity 245
prospective to, concurrent with, or retrospective to, the 246
provision of a nonemergency health care service, to determine 247
whether payment shall be made in full or shall be subject to an 248
adverse determination. Utilization review activity is 249
prohibited: 250

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1. To the extent restricted or prohibited by an agreement 251
with a health care provider; 252
2. For an emergency health care service; or 253
3. For a service provided to a patient who is experiencing 254
an emergency medical condition. 255
(i) "Utilization review entity" means an entity permitted 256
under the applicable agreement with a health care provider or 257
otherwise permitted by a provider that does not have such an 258
agreement to perform utilization review activities or upon whose 259
behalf utilization review activities are performed, including, 260
as applicable: 261
1. An authorized health insurer offering health insurance 262
as defined in s. 624.603, as well as any entity that offers a 263
commercial self-insurance fund as defined in s. 624.462(2) or 264
group self-insurance fund as described in s. 624.4621. 265
2. A health insurer that is subject to any of the 266
provisions of this chapter, as well as any entity that offers a 267
self-insurance plan or a group self-insurance plan. 268
3. A managed care plan as defined in s. 409.962. 269
4. A health maintenance organization as defined in s. 270
641.19. 271
5. A pharmacy benefit manager as defined in s. 624.490(1). 272
6. Any other individual or entity that provides, offers to 273
provide, or administers payment for hospital services, 274
outpatient services, medical services, prescription drugs, or 275

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other health care services to a person treated by a health care 276
professional or facility in this state under a policy, plan, 277
contract, or fund "health insurer" means an authorized insurer 278
offering health insurance as defined in s. 624.603, a managed 279
care plan as defined in s. 409.962(10), or a health maintenance 280
organization as defined in s. 641.19(12). 281
(2) Notwithstanding any other provision of law, a 282
utilization review entity that effective January 1, 2017, or six 283
(6) months after the effective date of the rule adopting the 284
prior authorization form, whichever is later, a health insurer, 285
or a pharmacy benefits manager on behalf of the health insurer, 286
which does not provide an electronic prior authorization process 287
for use by its contracted providers, shall only use the prior 288
authorization form that has been approved by the Financial 289
Services Commission for granting a prior authorization for a 290
medical procedure, course of treatment, or prescription drug 291
benefit. Such form shall be no longer than may not exceed two 292
pages in length, excluding any instructions or guiding 293
documentation, and must include all clinical documentation 294
necessary for the utilization review entity health insurer to 295
make a decision. At a minimum, the form must include: (1) 296
sufficient patient information to identify the member, date of 297
birth, full name, and Health Plan ID number; (2) provider name, 298
address and phone number; (3) the medical procedure, course of 299
treatment, or prescription drug benefit being requested, 300

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including the medical reason therefor, and all services tried 301
and failed; (4) any laboratory documentation required; and (5) 302
an attestation that all information provided is true and 303
accurate. 304
(3) The Financial Services Commission in consultation with 305
the Agency for Health Care Administration shall adopt by rule 306
guidelines for all prior authorization forms which ensure the 307
general uniformity of such forms. 308
(4) A utilization review entity must establish and offer a 309
secure, interactive online electronic prior authorization to 310
accept electronic prior authorization requests. The process of 311
electronic prior authorization must allow a person seeking a 312
prior authorization the ability to upload documentation if such 313
documentation is required by the utilization review entity to 314
adjudicate the prior authorization request. Once a provider 315
grants a health insurer access to a patient's electronic medical 316
record, the provider shall be deemed to have supplied all 317
information necessary for prior authorization of the health care 318
service, including, without limitation, all information that is 319
reasonably required by the health insurer, other than for an 320
emergency health care service or for a service provided to a 321
patient who is experiencing an emergency medical condition, in 322
advance of the provision of service, and the health insurer 323
asserts is missing as of the date of such service. Additional 324
information or documentation, regardless of whether the 325

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utilization review entity requests any additional information, 326
shall be deemed unnecessary, and deemed not required, for prior 327
authorization of the health care service, and any request for 328
additional information or any position of the utilization review 329
entity or any third party acting on behalf of the utilization 330
review entity regarding any lack of information from the 331
provider is prohibited from being used to deny, pend, or delay 332
prior authorization of the health care service. 333
(5)(4) Electronic prior authorization approvals do not 334
preclude benefit verification or medical review by the health 335
insurer under either the medical or pharmacy benefits. 336
(6) A utilization review entity's prior authorization 337
process is prohibited from requiring information that is not 338
needed to make a determination or facilitate a determination of 339
medical necessity of the requested medical procedure, course of 340
treatment, or prescription drug benefit. 341
(7) A utilization review entity shall disclose all of its 342
prior authorization requirements and restrictions, including any 343
written clinical criteria, in a publicly accessible manner on 344
its website. This information shall be explained in detail and 345
in clear and ordinary terms. 346
(8) A utilization review entity is prohibited from 347
implementing any new requirements or restrictions and from 348
making changes to existing requirements or restrictions on 349
obtaining prior authorization unless: 350

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(a) The changes have been available on a publicly 351
accessible website for at least 60 days before they are 352
implemented; 353
(b) Policyholders and health care providers who are 354
affected by the new requirements and restrictions or changes to 355
the requirements and restrictions are provided with a written 356
notice of the changes at least 60 days before they are 357
implemented, with such notice being delivered electronically or 358
by other means as agreed to by the policyholder or the health 359
care provider; and 360
(c) All applicable amendments to a provider's agreement 361
with the applicable health insurer or utilization review entity 362
have been obtained and memorialized in a mutually agreed-upon 363
writing before such implementation. 364
(9)(a) Utilization review entities shall, by March 31 of 365
each year, submit a report to the Office of Insurance Regulation 366
with the following data elements for the prior calendar year: 367
1. A list of all items and services requiring prior 368
authorization. 369
2. The percentage of standard prior authorization requests 370
approved by the utilization review entity and aggregated by item 371
or service. 372
3. The percentage of standard prior authorization requests 373
denied by the utilization review entity aggregated by item or 374
service. 375

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4. The percentage of standard prior authorization requests 376
approved by the utilization review entity after appeal by item 377
or service. 378
5. The percentage of prior authorization where the 379
timeframe for review was extended and request approved by item 380
or service. 381
6. The percentage of expedited prior authorization 382
requests approved by the utilization review entity by item or 383
service. 384
7. The percentage of expedited prior authorization 385
requests denied by the utilization review entity by item or 386
service. 387
8. The percentage of expedited prior authorization 388
requests approved by the utilization review entity after appeal 389
by item or service. 390
9. The average and median time between submission of a 391
request for prior authorization and the utilization review 392
entity's decision for standard prior authorizations by item or 393
service. 394
10. The average and median time between submission of a 395
request for prior authorization and the utilization review 396
entity's decision for expedited prior authorizations by item or 397
service. 398
(b) The Office of Insurance Regulation shall, by July 1 of 399
each year, publish a report on its website detailing the 400

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information in paragraph (a) submitted by utilization review 401
entities. 402
(10) Utilization review entities must ensure that all 403
adverse determinations are made by a physician licensed under 404
chapter 458 or chapter 459. The physician must: 405
(a) Possess a current and valid nonrestricted license to 406
practice medicine in this state; 407
(b) Be of the same specialty as the physician who 408
typically manages the medical condition or disease, or provides 409
the health care service involved in the request; 410
(c) Have at least 5 years of experience treating patients 411
with the medical condition or disease for which the health care 412
service is being requested; and 413
(d) Not have any direct or indirect financial arrangement 414
with the utilization review entity that rewards or incentivizes, 415
financially or otherwise, such physician in any way relating to 416
adverse determinations. 417
(11) Notice of an adverse determination shall be provided 418
by electronic mail to the health care provider that initiated 419
the prior authorization and to the patient. Notice required 420
under this subsection must include: 421
(a) The name, title, e-mail address, and telephone number 422
of the physician responsible for making the adverse 423
determination. 424
(b) The written clinical criteria, if any, and any 425

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internal rule, guideline, or protocol on which the utilization 426
review entity relied when making the adverse determination and 427
how those provisions apply to the patient's specific medical 428
circumstance. 429
(c) Information for the patient and the patient's health 430
care provider which describes the procedure through which the 431
patient or health care provider may request a copy of any report 432
developed by personnel performing the review that led to the 433
adverse determination. 434
(d) Information that explains to the patient and the 435
patient's health care provider how to appeal the adverse 436
determination. 437
(12) If a utilization review entity requires prior 438
authorization of a nonurgent health care service, the 439
utilization review entity shall grant a prior authorization or 440
make an adverse determination and notify the patient and the 441
patient's health care provider of the decision within 72 hours 442
after obtaining all necessary information to grant the prior 443
authorization or make the adverse determination. For purposes of 444
this subsection, the term "necessary information" includes the 445
results of any face-to-face clinical evaluation or second 446
opinion that may be required. 447
(13) A utilization review entity shall grant an expedited 448
prior authorization or make an expedited adverse determination 449
concerning an urgent health care service and notify the patient 450

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and the patient's health care provider of such expedited prior 451
authorization or adverse determination no later than 24 hours 452
after receiving all information needed to complete the review of 453
the requested urgent health care service. 454
(14)(a) A utilization review entity is prohibited from 455
requiring prior authorization for: 456
1. Prehospital transportation; 457
2. Provision of an emergency health care service; or 458
3. Provision of a service to a patient who is experiencing 459
an emergency medical condition. 460
(b) A utilization review entity is prohibited from 461
conducting utilization review activity, and from making any 462
adverse determinations, to the extent restricted or prohibited 463
by an agreement with a health care provider. A utilization 464
review entity is prohibited from performing any utilization 465
review activity, and from making any adverse determinations, 466
with respect to: 467
1. An emergency health care service; or 468
2. A service provided to a patient who experiences an 469
emergency medical condition. 470
(15) A utilization review entity is prohibited from 471
requiring prior authorization, and from making any adverse 472
determinations, for the provision of medications for opioid use 473
disorder. For purposes of this subsection, the term "medications 474
for opioid use disorder" means the use of medications, commonly 475

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prescribed in combination with counseling and behavioral 476
therapies, to provide a comprehensive approach to the treatment 477
of opioid use disorder. FDA-approved medications used to treat 478
opioid addiction include, but are not limited to, methadone, 479
buprenorphine, alone or in combination with naloxone, and 480
extended-release injectable naltrexone. Types of behavioral 481
therapies include, but are not limited to, individual therapy, 482
group counseling, family behavior therapy, motivational 483
incentives, and other modalities. 484
(16) A utilization review entity is prohibited from 485
revoking, limiting, conditioning, or restricting a prior 486
authorization if care is provided within 45 business days after 487
the date the health care provider receives the prior 488
authorization. A utilization review entity must pay, or cause 489
payment to be made to, the health care provider, without any 490
prepayment review or prepayment audit before such payment, at 491
the contracted payment rate for a health care service provided 492
by the health care provider per the prior authorization, unless: 493
(a) The health care provider knowingly and materially 494
misrepresented the health care service in the prior 495
authorization request with the specific intent to deceive and 496
obtain an unlawful payment from the utilization review entity; 497
(b) The health care service was no longer a covered 498
benefit, and medical necessity did not constitute a basis for 499
such noncovered benefit status, on the day the health care 500

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service was provided, and the utilization review entity notified 501
the health care provider in writing of these facts before the 502
health care service being provided; 503
(c) The authorized service was never performed; or 504
(d) The patient was no longer enrolled under the 505
applicable health plan and, on that basis, was not eligible for 506
health care coverage from the applicable health insurer or self-507
insured plan on the day the care was provided, and the 508
utilization review entity notified the health care provider in 509
writing of these facts before the health care service being 510
provided. 511
(17) If a utilization review entity requires a prior 512
authorization for a health care service for the treatment of a 513
chronic or long-term care condition, the prior authorization 514
shall remain valid for the length of the treatment and the 515
utilization review entity is prohibited from requiring the 516
patient to obtain a prior authorization again for the health 517
care service. 518
(18) A utilization review entity is prohibited from 519
imposing an additional prior authorization requirement with 520
respect to a surgical or otherwise invasive procedure, or any 521
item furnished as part of the surgical or invasive procedure, if 522
the procedure or item is furnished during the perioperative 523
period of another procedure for which prior authorization was 524
granted by the health insurer. 525

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(19) If there is a change in coverage or approval criteria 526
for a previously authorized health care service, the change in 527
coverage or approval criteria is prohibited from adversely 528
affecting an enrollee who received prior authorization before 529
the effective date of the change for the remainder of the 530
enrollee's plan year. 531
(20) A utilization review entity shall continue to honor a 532
prior authorization it has granted to an enrollee when the 533
enrollee changes products under the same health insurer. 534
(21) Any failure by a utilization review entity to comply 535
with the deadlines and other requirements specified in this 536
section shall result in any health care services subject to 537
review to be automatically deemed authorized by the utilization 538
review entity. 539
(22) Except as otherwise provided in paragraphs (16)(a)-540
(d), prior authorization constitutes a conclusive determination 541
of the medical necessity of the authorized health care service 542
and an irrevocable obligation to pay for such authorized health 543
care service. 544
(23)(a) This section prohibits an agreement with a health 545
care provider to restrict, limit, prohibit, or substitute a 546
utilization review activity or prior authorization. 547
(b) Nothing in this section shall be construed to: 548
1. Limit in any way the restrictions or prohibitions on 549
adverse determinations under an agreement with a health care 550

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provider, nor to imply permission for, or applicability of, 551
adverse determinations for emergency health care services. 552
2. Restrict, limit, or prohibit in any way prior 553
authorizations under an agreement between a provider and a 554
utilization review entity, nor to restrict, limit, or prohibit a 555
provider's rights to contest, reject, or oppose any prior 556
authorization activities. 557
(24) In the instance of a violation of this section, a 558
provider shall have a private cause of action to proceed against 559
the health insurer or utilization review entity in the 560
applicable tribunal for the violation. 561
Section 3. Section 627.6131, Florida Statutes, is amended 562
to read: 563
627.6131 Prompt payment of claims.— 564
(1) The contract shall include the following provision: 565
"Time of Payment of Claims: After receiving written proof of 566
loss, the health insurer shall will pay monthly all claims. 567
Claims benefits then due for ...(type of benefit).... Benefits 568
for any other loss covered by this policy shall will be paid as 569
soon as the health insurer receives proper written proof." 570
(2) As used in this section, the term: 571
(a) "Claim" for a noninstitutional provider means a paper 572
HCFA 1500 claim form, or its successor, or an electronic billing 573
instrument submitted to the health insurer's designated location 574
that consists of the ANSI ASC X12N 837P standard HCFA 1500 data 575

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set, or its successor, that has all mandatory entries for a 576
physician licensed under chapter 458, chapter 459, chapter 460, 577
chapter 461, or chapter 463, or psychologists licensed under 578
chapter 490 or any appropriate billing instrument as designated 579
by the provider that has all mandatory entries for any other 580
noninstitutional provider. For institutional providers, "claim" 581
means a paper CMS-1450 claim form or its successor, or an 582
electronic billing instrument submitted to the health insurer's 583
designated location that consists of the ANSI ASC X12N 837I 584
standard UB-92 data set, or its successor, with entries stated 585
as mandatory by the National Uniform Billing Committee. 586
(b) "Clean claim" means a completed form, or completed 587
electronic billing instrument, containing all information 588
required under the applicable form or electronic billing 589
instrument, as well as information reasonably required by the 590
health insurer, other than for emergency services and care as 591
defined in s. 395.002(9), in advance of the provision of service 592
by the health insurer to substantiate the claim. 593
(c) "Electronic medical record" means the digital record 594
of a patient's information that may be accessed through 595
electronic means, via portal or other method of electronic 596
access, which may include information regarding the patient's 597
medical history, medical condition, medical treatment, 598
laboratory results, diagnostic reports, and clinical notes. 599
(d) "Emergency health care services" has the same meaning 600

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as "emergency services and care" as defined in s. 395.002(9). 601
(e) "Health insurer" means any entity that offers health 602
insurance coverage, whether through a fully insured plan or a 603
self-insured plan or fund, including, as applicable: 604
1. An authorized health insurer offering health insurance 605
as defined in s. 624.603, as well as any entity that offers a 606
commercial self-insurance fund as defined in s. 624.462(2) or a 607
group self-insurance fund as described in s. 624.4621. 608
2. A health insurer that is subject to any of the 609
provisions of this chapter, as well as any entity that offers a 610
self-insurance plan or a group self-insurance plan. 611
(f) "Insured ineligibility" means that the insured was no 612
longer enrolled in the health plan at the time of receiving the 613
applicable service. 614
(g) "Overpayment" means payment made upon a claim that is:615
1. Billed in error; 616
2. A duplicate claim; or 617
3. Billed for a service rendered to a patient in spite of 618
insured ineligibility. 619
620
A request for overpayment is limited to a billing error, 621
duplicate bill, or insured ineligibility. 622
(3) All claims for payment or overpayment, whether 623
electronic or nonelectronic: 624
(a) Are considered received on the date the claim is 625

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received by the health insurer at its designated claims-receipt 626
location or the date the claim for overpayment claim is received 627
by the provider at its designated location. 628
(b) As to providers' claims for payment, must be mailed or 629
electronically transferred to the primary health insurer within 630
6 months after the following have occurred: 631
1. Discharge for inpatient services or the date of service 632
for outpatient services; and 633
2. The provider has been furnished with the correct name 634
and address of the patient's health insurer. 635
636
All providers' claims for payment, whether electronic or 637
nonelectronic, must be mailed or electronically transferred to 638
the secondary health insurer within 45 90 days after final 639
determination by the primary health insurer. A provider's claim 640
is considered submitted on the date it is electronically 641
transferred or mailed. 642
(c) Must not duplicate a claim previously submitted unless 643
it is determined that the original claim was not received or is 644
otherwise lost. 645
(4) For all electronically submitted claims, a health 646
insurer shall: 647
(a) Within 24 hours after the beginning of the next 648
business day after receipt of the claim, provide to the 649
electronic source submitting the claim an electronic 650

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acknowledgment of the receipt of the claim, accompanied by a 651
statement indicating the health insurer's position as to whether 652
the claim is a clean claim or is missing any information that is 653
required under the applicable electronic billing instrument, as 654
described in paragraph (2)(a), or that was reasonably required 655
by the health insurer, other than for emergency health care 656
services, in advance of the provision of service to substantiate 657
to the electronic source submitting the claim, and the health 658
insurer asserts is missing as of the date of service. 659
(b) Within 15 20 days after receipt of the claim, pay the 660
claim or notify a provider or designee if a claim is denied or 661
contested. Notice of the health insurer's action on the claim 662
and payment of the claim is considered to be made on the date 663
the notice or payment was received by the provider mailed or 664
electronically transferred. 665
(c)1. Notification of the health insurer's determination 666
of a contested claim must be accompanied by an itemized list of 667
any additional information that is required under the applicable 668
billing instrument, as described in paragraph (2)(a), or that 669
was reasonably required by the health insurer, other than for 670
emergency health care services, in advance of the provision of 671
service to substantiate the claim, and the health insurer 672
asserts is missing as of the date of such service or documents 673
the insurer can reasonably determine are necessary to process 674
the claim. 675

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2. A provider must submit the additional information or 676
documentation, as specified on the itemized list, within 30 35 677
days after receipt of the notification of contestation unless, 678
within the 30-day period, the provider notifies the health 679
insurer of the provider's position that a clean claim has been 680
submitted. Additional information is considered submitted on the 681
date it is electronically transferred or mailed. The health 682
insurer is prohibited from requesting may not request duplicate 683
documents. 684
(d) For purposes of this subsection, electronic means of 685
transmission of claims, notices, documents, forms, and payments 686
shall be used to the greatest extent possible by the health 687
insurer and the provider. 688
(e) A claim that was contested by the health insurer must 689
be paid or denied within 30 90 days after receipt of the 690
additional information requested claim. Failure to pay or deny a 691
claim within 90 120 days after receipt of the claim, regardless 692
of whether contested by the health insurer, creates an 693
uncontestable obligation to pay the claim as submitted by the 694
provider. 695
(5) For all nonelectronically submitted claims, a health 696
insurer shall: 697
(a) Within 15 days following receipt of the claim 698
Effective November 1, 2003, provide to the provider or its 699
designee: 700

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1. An acknowledgment of receipt of the claim, accompanied 701
by a statement indicating the health insurer's position as to 702
whether the claim is a clean claim or the claim is missing any 703
information that is required under the applicable paper billing 704
form, as described in paragraph (2)(a), or that was reasonably 705
required by the health insurer, other than for emergency health 706
care services, in advance of the provision of service to 707
substantiate the claim, and the health insurer asserts is 708
missing as of the date of service; or 709
2. within 15 days after receipt of the claim to the 710
provider or provide a provider within 15 days after receipt with 711
Electronic access to the status of the a submitted claim, which 712
status must indicate the health insurer's position as to whether 713
the claim is a clean claim or missing any information described 714
in subparagraph 1. 715
(b) Within 30 40 days after receipt of the claim, pay the 716
claim or notify a provider or designee if a claim is denied or 717
contested. Notice of the health insurer's action on the claim 718
and payment of the claim is considered to be made on the date 719
the notice or payment was received by the provider mailed or 720
electronically transferred. 721
(c)1. Notification of the health insurer's determination 722
of a contested claim must be accompanied by an itemized list of 723
any additional information that is required under the applicable 724
form or billing instrument, as described in paragraph (2)(a), or 725

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that was reasonably required by the health insurer, other than 726
for emergency health care services, in advance of the provision 727
of service to substantiate the claim, and the health insurer 728
asserts is missing as of the date of such service or documents 729
the insurer can reasonably determine are necessary to process 730
the claim. 731
2. A provider must submit the additional information or 732
documentation, as specified on the itemized list, within 30 35 733
days after receipt of the notification of contestation unless, 734
within the 30-day period, the provider notifies the health 735
insurer of its position that a clean claim has been submitted. 736
Additional information is considered submitted on the date it is 737
electronically transferred or mailed. The health insurer is 738
prohibited from requesting may not request duplicate documents. 739
(d) For purposes of this subsection, electronic means of 740
transmission of claims, notices, documents, forms, and payments 741
shall be used to the greatest extent possible by the health 742
insurer and the provider. 743
(e) A claim that was contested by the health insurer must 744
be paid or denied within 30 120 days after receipt of the 745
additional information requested claim. Failure to pay or deny a 746
claim within 90 140 days after receipt of the claim, regardless 747
of whether contested by the health insurer, creates an 748
uncontestable obligation to pay the claim as submitted by the 749
provider. 750

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(6) Regardless of whether a claim has been submitted 751
electronically or nonelectronically, and notwithstanding any 752
other provision of this section to the contrary: 753
(a) Once a provider grants a health insurer access to a 754
patient's electronic medical record, the provider shall be 755
deemed to have supplied all information necessary to pay the 756
claim, including, without limitation, all information that is 757
required under the applicable billing instrument and that was 758
reasonably required by the health insurer, other than for 759
emergency health care services, in advance of the provision of 760
service to substantiate the claim. Additional information or 761
documentation, regardless of whether the health insurer requests 762
any additional information, shall be deemed unnecessary, and 763
deemed not required for payment of the claim, and any request 764
for additional information, and any position of the health 765
insurer or any third party acting on behalf of the health 766
insurer regarding any lack of information from the provider, is 767
prohibited from being used to deny, reduce, offset, withhold, 768
pend, or delay payment of the claim. 769
(b) For instances in which notice of access to the 770
electronic medical record has been provided to the health 771
insurer, the claim must be paid or denied within 30 days of such 772
notice to the health insurer. Failure to pay or deny a claim, 773
for which the health insurer has been provided notice of access 774
to the electronic medical record within 75 days after receipt of 775

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such notice creates an uncontestable obligation to pay the claim 776
as submitted by the provider. 777
(7)(6) If a health insurer determines that it has made an 778
overpayment to a provider for services rendered to an insured, 779
the health insurer must make an overpayment a claim for such 780
overpayment to the provider's designated location. A health 781
insurer that makes an overpayment a claim for overpayment to a 782
provider under this section shall give the provider a written or 783
electronic statement specifying the basis for the retrospective 784
retroactive denial or payment adjustment. The health insurer 785
must also identify the claim or claims, or portion thereof, as 786
to which the health insurer alleges overpayment claim; and the 787
specific invoice number submitted with or on the claim portion 788
thereof, for which a claim for overpayment is submitted. Except 789
as provided in subparagraph (a).3, there shall be no denial, 790
reduction, offset, withholding, pending, or delay of payment, or 791
other negative impact, regardless of whether by the health 792
insurer or any third party acting on behalf of such health 793
insurer, on payment of any other claim of the provider on the 794
basis of the overpayment allegation. 795
(a) If an overpayment determination is the result of 796
retrospective retroactive review or retrospective audit of 797
coverage decisions or payment levels not related to fraud, a 798
health insurer shall adhere to the following procedures: 799
1. All overpayment claims for overpayment must be received 800

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by the submitted to a provider within 18 30 months after the 801
health insurer's payment of the claim. A provider must pay, 802
deny, or contest the health insurer's claim for overpayment 803
claim within 40 days after the receipt of the overpayment claim. 804
All contested overpayment claims for overpayment must be paid or 805
denied within 120 days after receipt of the overpayment claim. 806
Failure to pay or deny an overpayment and claim within 140 days 807
after receipt creates an uncontestable obligation to pay the 808
overpayment claim. 809
2. A provider that denies or contests a health insurer's 810
overpayment claim for overpayment or any portion of an 811
overpayment a claim shall notify the health insurer, in writing, 812
within 40 35 days after the provider receives the overpayment 813
claim that such overpayment the claim for overpayment is 814
contested or denied. The notice that the overpayment claim for 815
overpayment is denied or contested must identify the denied or 816
contested portion of the overpayment claim and the specific 817
reason for contesting or denying the overpayment claim and, if 818
contested, must include a request for additional information. If 819
the health insurer submits additional information, the health 820
insurer must, within 35 days after receipt of the request, mail 821
or electronically transfer the information to the provider. The 822
provider shall pay or deny the overpayment claim for overpayment 823
within 45 days after receipt of the information. The notice from 824
the provider regarding denial or contestation of the overpayment 825

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claim is considered made on the date the notice is mailed or 826
electronically transferred by the provider. 827
3. The health insurer is prohibited from denying, 828
reducing, offsetting, withholding, pending, or delaying may not 829
reduce payment to the provider for other services unless the 830
provider agrees to the denial, reduction, offset, withholding, 831
pending, or delay of payment in writing or fails to respond to 832
the health insurer's overpayment claim as required by this 833
paragraph. 834
4. Payment of an overpayment claim is considered made on 835
the date the payment was mailed or electronically transferred. 836
An overdue payment of a claim bears simple interest at the rate 837
of 12 percent per year. Interest on an overdue payment for an 838
overpayment a claim for an overpayment begins to accrue when the 839
overpayment claim should have been paid, denied, or contested. 840
(b) An overpayment A claim is prohibited for overpayment 841
shall not be permitted beyond 18 30 months after the health 842
insurer's payment of a claim, except that overpayment claims for 843
overpayment may be sought beyond that time from providers 844
convicted of fraud pursuant to s. 817.234. 845
(8)(7) Payment of a claim is considered made on the date 846
the payment was mailed or electronically transferred. An overdue 847
payment of a claim bears simple interest of 15 12 percent per 848
year, to be calculated upon the full total amount that should 849
have been paid on the claim within the applicable time period 850

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specified in this section. If an applicable court, arbitration 851
tribunal, or other binding legal process determines that a claim 852
that was paid at a lesser amount should have been paid at a full 853
total amount, whether under a breach of contract legal claim, a 854
legal claim under a statutory private cause of action, or other 855
basis, the 15 percent per year interest shall be calculated upon 856
the full total amount, rather than upon the difference between 857
the full total amount and the amount that was actually paid. If 858
an applicable court, arbitration tribunal, or other binding 859
legal process determines that a claim was subject to an 860
inappropriate or impermissible denial or partial denial, whether 861
in a breach of contract, statute, common law, or otherwise, 862
interest shall be calculated upon the full total amount that 863
should have been paid on the claim within the applicable time 864
period for payment specified in this section, and the act of 865
denial or partial denial shall be deemed not to have in any way 866
tolled the time period for such payment. Interest on the full 867
total amount that should have been paid on the claim within the 868
applicable time period specified in this section an overdue 869
payment for a claim or for any portion of a claim begins to 870
accrue when the claim should have been paid, denied, or 871
contested. The interest must be paid along with, and in addition 872
to, the payment for the satisfaction of the full total amount of 873
the claim, as determined by an applicable court, arbitration 874
tribunal, or other binding legal process is payable with the 875

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payment of the claim. 876
(9)(8) For all contracts entered into or renewed on or 877
after October 1, 2002, a health insurer's internal dispute 878
resolution process related to a denied claim not under active 879
review by a mediator, arbitrator, or third-party dispute entity 880
must be finalized within 60 days after the receipt of the 881
provider's request for review or appeal. Notwithstanding any 882
provision of this section to the contrary, when the provider and 883
health insurer disagree as to interpretation of contractual or 884
statutory language, the provider is not required to participate 885
in the health insurer's internal dispute resolution process. 886
(10)(9) A provider or any representative of a provider, 887
regardless of whether the provider is under contract with the 888
health insurer, is prohibited from collecting or attempting may 889
not collect or attempt to collect money from, maintaining 890
maintain any action at law against, or reporting report to a 891
credit agency an insured for payment of covered services for 892
which the health insurer contested or denied the provider's 893
claim. This prohibition applies during the pendency of any claim 894
for payment made by the provider to the health insurer for 895
payment of the services or internal dispute resolution process 896
to determine whether the health insurer is liable for the 897
services. For a claim, this pendency applies from the date the 898
claim or a portion of the claim is denied to the date of the 899
completion of the health insurer's internal dispute resolution 900

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process, not to exceed 60 days. This subsection does not 901
prohibit the collection by the provider of copayments, 902
coinsurance, or deductible amounts due the provider. 903
(10) The provisions of this section may not be waived, 904
voided, or nullified by contract. 905
(11) A health insurer is prohibited from retrospectively 906
denying may not retroactively deny a claim because of insured 907
ineligibility more than 90 days 1 year after the date of payment 908
of the claim. 909
(12) A health insurer shall pay a contracted primary care 910
or admitting physician, pursuant to such physician's contract, 911
for providing inpatient services in a contracted hospital to an 912
insured if such services are determined by such physician the 913
health insurer to be medically necessary and, regardless of the 914
health plan's determination of medical necessity, are otherwise 915
covered services under the health insurer's contract with the 916
contract holder. 917
(13) Upon written notification by an insured, a health an 918
insurer shall investigate any claim of improper billing of the 919
insured by a physician, hospital, or other health care provider 920
for a health care service alleged to not actually have been 921
received. The health insurer shall determine if the insured 922
actually received the applicable service was properly billed for 923
only those procedures and services that the insured actually 924
received. If the health insurer determines that the insured did 925

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not actually receive the applicable service has been improperly 926
billed, the health insurer shall notify the insured and the 927
provider of its findings and shall reduce the amount of payment 928
to the provider by the amount for the service that was not 929
actually received determined to be improperly billed. If a 930
reduction is made due to such notification by the insured, the 931
insurer shall pay to the insured 20 percent of the amount of the 932
reduction up to $500. 933
(14) A permissible error ratio of 5 percent is established 934
for health insurer's claims payment violations of paragraphs 935
(4)(a), (b), (c), and (e) and (5)(a), (b), (c), and (e). If the 936
error ratio of a particular health insurer does not exceed the 937
permissible error ratio of 5 percent for an audit period, no 938
fine shall be assessed for the noted claims violations for the 939
audit period. The error ratio shall be determined by dividing 940
the number of claims with violations found on a statistically 941
valid sample of claims for the audit period by the total number 942
of claims in the sample. If the error ratio exceeds the 943
permissible error ratio of 5 percent, a fine may be assessed 944
according to s. 624.4211 for those claims payment violations 945
which exceed the error ratio. Notwithstanding the provisions of 946
this section, the office may fine a health insurer for claims 947
payment violations of paragraphs (4)(e) and (5)(e) which create 948
an uncontestable obligation to pay the claim as submitted by the 949
provider. The office shall refrain from imposing a not fine upon 950

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a health insurer insurers for violations which the office 951
determines were due to circumstances beyond the health insurer's 952
control. 953
(15) This section is applicable only to a major medical 954
expense health insurance policy as defined in s. 627.643(2)(e) 955
offered by a group or an individual health insurer licensed 956
under pursuant to chapter 624, including a preferred provider 957
policy under s. 627.6471 and an exclusive provider organization 958
under s. 627.6472 or a group or individual insurance contract 959
that only provides direct payments to dentists for enumerated 960
dental services, or other health insurance coverage, policy, or 961
fund, regardless of whether fully insured or self-insured, 962
offered or administered by a health insurer. 963
(16) Notwithstanding paragraph (4)(b), where an electronic 964
pharmacy claim is submitted to a pharmacy benefits manager 965
acting on behalf of a health insurer, the pharmacy benefits 966
manager shall, within 30 days of receipt of the claim, pay the 967
claim or notify a provider or designee if a claim is denied or 968
contested. Notice of the health insurer's action on the claim 969
and payment of the claim is considered to be made on the date 970
the notice or payment was received by the provider mailed or 971
electronically transferred. 972
(17) Notwithstanding paragraph (5)(a), effective November 973
1, 2003, where a nonelectronic pharmacy claim is submitted to a 974
pharmacy benefits manager acting on behalf of a health insurer, 975

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the pharmacy benefits manager shall provide acknowledgment of 976
receipt of the claim within 30 days after receipt of the claim 977
to the provider or provide a provider within 30 days after 978
receipt with electronic access to the status of a submitted 979
claim. 980
(18) Notwithstanding the 18-month 30-month period provided 981
in subsection (7) (6), all overpayment claims for overpayment 982
submitted to a provider licensed under chapter 395, chapter 458, 983
chapter 459, chapter 460, chapter 461, chapter 463, chapter 466, 984
or chapter 490 must be submitted to the provider within 12 985
months after the health insurer's payment of the claim. An 986
overpayment A claim to a provider licensed under chapter 395, 987
chapter 458, chapter 459, chapter 460, chapter 461, chapter 463, 988
chapter 466, or chapter 490 is prohibited for overpayment may 989
not be permitted beyond 12 months after the health insurer's 990
payment of a claim, except that overpayment claims for 991
overpayment may be sought beyond that time from providers 992
convicted of fraud pursuant to s. 817.234. 993
(19) Notwithstanding any other provision of this section, 994
all claims for underpayment from a provider licensed under 995
chapter 395, chapter 458, chapter 459, chapter 460, chapter 461, 996
or chapter 466 must be submitted to the health insurer within 12 997
months after the health insurer's payment of the claim. A claim 998
for underpayment by a provider licensed under chapter 395, 999
chapter 458, chapter 459, chapter 460, chapter 461, or chapter 1000

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466 is prohibited may not be permitted beyond 12 months after 1001
the health insurer's payment of a claim. 1002
(20) Nothing in this section shall be interpreted to 1003
limit, restrict, or negatively impact any legal claim by a 1004
provider or health insurer for breach of contract, statutory or 1005
regulatory violation, or a common-law cause of action, nor to 1006
shorten or otherwise negatively impact the statute of 1007
limitations timeframe for bringing any such legal claim. 1008
(21) A health insurer is prohibited from requesting 1009
information from a contracted or noncontracted provider which 1010
does not apply to the medical condition at issue for the 1011
purposes of adjudicating a clean claim. 1012
(22) A health insurer is prohibited from requesting a 1013
contracted or noncontracted provider to resubmit claim 1014
information that the contracted or noncontracted provider can 1015
document it has already provided to the health insurer or that 1016
is contained inside the electronic medical record to which the 1017
health insurer has been provided access. 1018
(23) Notwithstanding any other provision of this section 1019
to the contrary, a health insurer is prohibited from requiring 1020
any information from a provider before the provision of 1021
emergency health care services as a condition of payment of a 1022
claim, as a basis for denying, delaying, offsetting, 1023
withholding, or reducing payment of a claim, or in contesting 1024
whether the claim is a clean claim. 1025

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(24) In an instance of a violation of this section, a 1026
provider shall have a private cause of action to proceed against 1027
the health insurer in the applicable tribunal for the violation. 1028
(25)(20)(a) A contract between a health insurer and a 1029
dentist licensed under chapter 466 for the provision of services 1030
to an insured is prohibited from specifying may not specify 1031
credit card payment as the only acceptable method for payments 1032
from the health insurer to the dentist. 1033
(b) When a health insurer employs the method of claims 1034
payment to a dentist through electronic funds transfer, 1035
including, but not limited to, virtual credit card payment, the 1036
health insurer shall notify the dentist as provided in this 1037
paragraph and obtain the dentist's consent before employing the 1038
electronic funds transfer. The dentist's consent described in 1039
this paragraph applies to the dentist's entire practice. For the 1040
purpose of this paragraph, the dentist's consent, which may be 1041
given through e-mail, must bear the signature of the dentist. 1042
Such signature includes an electronic or digital signature if 1043
the form of signature is recognized as a valid signature under 1044
applicable federal law or state contract law or an act that 1045
demonstrates express consent, including, but not limited to, 1046
checking a box indicating consent. The health insurer or dentist 1047
is prohibited from requiring may not require that a dentist's 1048
consent as described in this paragraph be made on a patient-by-1049
patient basis. The notification provided by the health insurer 1050

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to the dentist must include all of the following: 1051
1. The fees, if any, associated with the electronic funds 1052
transfer. 1053
2. The available methods of payment of claims by the 1054
health insurer, with clear instructions to the dentist on how to 1055
select an alternative payment method. 1056
(c) A health insurer that pays a claim to a dentist 1057
through automated clearinghouse transfer is prohibited from 1058
charging may not charge a fee solely to transmit the payment to 1059
the dentist unless the dentist has consented to the fee. 1060
(d) This subsection applies to contracts delivered, 1061
issued, or renewed on or after January 1, 2025. 1062
(e) The office has all rights and powers to enforce this 1063
subsection as provided by s. 624.307. 1064
(f) The commission may adopt rules to implement this 1065
subsection. 1066
(26)(21)(a) A health insurer is prohibited from denying 1067
may not deny any claim subsequently submitted by a dentist 1068
licensed under chapter 466 for procedures specifically included 1069
in a prior authorization unless at least one of the following 1070
circumstances applies for each procedure denied: 1071
1. Benefit limitations, such as annual maximums and 1072
frequency limitations not applicable at the time of the prior 1073
authorization, are reached subsequent to issuance of the prior 1074
authorization. 1075

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2. The documentation provided by the person submitting the 1076
claim fails to support the claim as originally authorized. 1077
3. Subsequent to the issuance of the prior authorization, 1078
new procedures are provided to the patient or a change in the 1079
condition of the patient occurs such that the prior authorized 1080
procedure would no longer be considered medically necessary, 1081
based on the prevailing standard of care. 1082
4. Subsequent to the issuance of the prior authorization, 1083
new procedures are provided to the patient or a change in the 1084
patient's condition occurs such that the prior authorized 1085
procedure would at that time have required disapproval pursuant 1086
to the terms and conditions for coverage under the patient's 1087
plan in effect at the time the prior authorization was issued. 1088
5. The denial of the claim was due to one of the 1089
following: 1090
a. Another payor is responsible for payment. 1091
b. The dentist has already been paid for the procedures 1092
identified in the claim. 1093
c. The claim was submitted fraudulently, or the prior 1094
authorization was based in whole or material part on erroneous 1095
information provided to the health insurer by the dentist, 1096
patient, or other person not related to the health insurer. 1097
d. The person receiving the procedure was not eligible to 1098
receive the procedure on the date of service. 1099
e. The services were provided during the grace period 1100

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established under s. 627.608 or applicable federal regulations, 1101
and the dental insurer notified the provider that the patient 1102
was in the grace period when the provider requested eligibility 1103
or enrollment verification from the dental insurer, if such 1104
request was made. 1105
(b) This subsection applies to all contracts delivered, 1106
issued, or renewed on or after January 1, 2025. 1107
(c) The office has all rights and powers to enforce this 1108
subsection as provided by s. 624.307. 1109
(d) The commission may adopt rules to implement this 1110
subsection. 1111
Section 4. Section 641.3155, Florida Statutes, is amended 1112
to read: 1113
641.3155 Prompt payment of claims.— 1114
(1) As used in this section, the term: 1115
(a) "Claim" for a noninstitutional provider means a paper 1116
HCFA 1500 claim form, or its successor, or an electronic billing 1117
instrument submitted to the health maintenance organization's 1118
designated location that consists of the ANSI ASC X12N 837P 1119
standard HCFA 1500 data set, or its successor, that has all 1120
mandatory entries for a physician licensed under chapter 458, 1121
chapter 459, chapter 460, chapter 461, or chapter 463, or 1122
psychologists licensed under chapter 490 or any appropriate 1123
billing instrument as designated by the provider that has all 1124
mandatory entries for any other noninstitutional provider. For 1125

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institutional providers, "claim" means a paper CMS-1450 claim 1126
form, or its successor, or an electronic billing instrument 1127
submitted to the health maintenance organization's designated 1128
location that consists of the ANSI ASC X12N 837I standard UB-92 1129
data set or its successor with entries stated as mandatory by 1130
the National Uniform Billing Committee. 1131
(b) "Clean claim" means a completed form, or completed 1132
electronic billing instrument, containing all information 1133
required under the applicable form or electronic billing 1134
instrument, as well as information reasonably required by the 1135
health maintenance organization, other than for emergency 1136
services and care as defined in s. 641.19, in advance of the 1137
provision of service by the health maintenance organization to 1138
substantiate the claim. 1139
(c) "Electronic medical record" means the digital record 1140
of a patient's information that may be accessed through 1141
electronic means, via portal or other method of electronic 1142
access, which may include information regarding the patient's 1143
medical history, medical condition, medical treatment, 1144
laboratory results, diagnostic reports, and clinical notes. 1145
(d) "Emergency health care service" has the same meaning 1146
as "emergency services and care" as defined in s. 641.19. 1147
(e) "Enrollee ineligibility" means that the enrollee was 1148
no longer enrolled in the health maintenance organization at the 1149
time of receiving the applicable service. 1150

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(f) "Overpayment" means payment made upon a claim that is:1151
1. Billed in error; 1152
2. A duplicate claim; or 1153
3. Billed for a service rendered to a patient in spite of 1154
enrollee ineligibility. 1155
1156
A request for overpayment is limited to a billing error, 1157
duplicate bill, or enrollee ineligibility. 1158
(2) All claims for payment or overpayment, whether 1159
electronic or nonelectronic: 1160
(a) Are considered received on the date the claim is 1161
received by the health maintenance organization at its 1162
designated claims-receipt location or the date the overpayment a 1163
claim for overpayment is received by the provider at its 1164
designated location. 1165
(b) As to providers' claims for payment, must be mailed or 1166
electronically transferred to the primary organization within 6 1167
months after the following have occurred: 1168
1. Discharge for inpatient services or the date of service 1169
for outpatient services; and 1170
2. The provider has been furnished with the correct name 1171
and address of the patient's health maintenance organization. 1172
1173
All providers' claims for payment, whether electronic or 1174
nonelectronic, must be mailed or electronically transferred to 1175

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the secondary organization within 45 90 days after final 1176
determination by the primary organization. A provider's claim is 1177
considered submitted on the date it is electronically 1178
transferred or mailed. 1179
(c) Must not duplicate a claim previously submitted unless 1180
it is determined that the original claim was not received or is 1181
otherwise lost. 1182
(3) For all electronically submitted claims, a health 1183
maintenance organization shall: 1184
(a) Within 24 hours after the beginning of the next 1185
business day after receipt of the claim, provide to the 1186
electronic source submitting the claim an electronic 1187
acknowledgment of the receipt of the claim, accompanied by a 1188
statement indicating the health maintenance organization's 1189
position as to whether the claim is a clean claim or whether the 1190
claim is missing any information that is required under the 1191
applicable electronic billing instrument described in paragraph 1192
(1)(a) or that was reasonably required by the health maintenance 1193
organization, other than for emergency health care services, in 1194
advance of the provision of service to substantiate to the 1195
electronic source submitting the claim, and the health 1196
maintenance organization asserts is missing as of the date of 1197
service. 1198
(b) Within 15 20 days after receipt of the claim, pay the 1199
claim or notify a provider or designee if a claim is denied or 1200

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contested. Notice of the health maintenance organization's 1201
action on the claim and payment of the claim is considered to be 1202
made on the date the notice or payment was received by the 1203
provider mailed or electronically transferred. 1204
(c)1. Notification of the health maintenance 1205
organization's determination of a contested claim must be 1206
accompanied by an itemized list of any additional information 1207
required under the applicable billing instrument described in 1208
paragraph (1)(a) or that was reasonably required by the health 1209
maintenance organization, other than for emergency health care 1210
services, in advance of the provision of service to substantiate 1211
the claim, and the health maintenance organization asserts is 1212
missing as of the date of such service or documents the insurer 1213
can reasonably determine are necessary to process the claim. 1214
2. A provider must submit the additional information or 1215
documentation, as specified on the itemized list, within 30 35 1216
days after receipt of the notification of contestation unless, 1217
within the 30-day period, the provider notifies the health 1218
maintenance organization of the provider's position that a clean 1219
claim has been submitted. Additional information is considered 1220
submitted on the date it is electronically transferred or 1221
mailed. The health maintenance organization is prohibited from 1222
requesting may not request duplicate documents. 1223
(d) For purposes of this subsection, electronic means of 1224
transmission of claims, notices, documents, forms, and payment 1225

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shall be used to the greatest extent possible by the health 1226
maintenance organization and the provider. 1227
(e) A claim that was contested by the health maintenance 1228
organization must be paid or denied within 30 90 days after 1229
receipt of the additional information requested claim. Failure 1230
to pay or deny a claim within 90 120 days after receipt of the 1231
claim, regardless of whether contested by the health maintenance 1232
organization, creates an uncontestable obligation to pay the 1233
claim. 1234
(4) For all nonelectronically submitted claims, a health 1235
maintenance organization shall: 1236
(a) Within 15 days following receipt of the claim 1237
Effective November 1, 2003, provide to the provider, or 1238
designee, who submitted the claim: 1239
1. An acknowledgment of receipt of the claim, accompanied 1240
by a statement indicating the health maintenance organization's 1241
position as to whether the claim is a clean claim or the claim 1242
is missing any information that is required under the applicable 1243
paper billing form, as described in paragraph (1)(a), or that 1244
was reasonably required by the health maintenance organization, 1245
other than for emergency health care services, in advance of the 1246
provision of service to substantiate the claim, and the health 1247
maintenance organization asserts is missing as of the date of 1248
service; or 1249
2. within 15 days after receipt of the claim to the 1250

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provider or designee or provide a provider or designee within 15 1251
days after receipt with Electronic access to the status of the a 1252
submitted claim, which status must indicate the health 1253
maintenance organization's position as to whether the claim is a 1254
clean claim or missing any information described in subparagraph 1255
1. 1256
(b) Within 30 40 days after receipt of the claim, pay the 1257
claim or notify a provider or designee if a claim is denied or 1258
contested. Notice of the health maintenance organization's 1259
action on the claim and payment of the claim is considered to be 1260
made on the date the notice or payment was received by the 1261
provider mailed or electronically transferred. 1262
(c)1. Notification of the health maintenance 1263
organization's determination of a contested claim must be 1264
accompanied by an itemized list of any additional information 1265
required under the applicable form or billing instrument 1266
described in paragraph (1)(a), or that was reasonably required 1267
by the health maintenance organization, other than for emergency 1268
health care services, in advance of the provision of service to 1269
substantiate the claim, and the health maintenance organization 1270
asserts is missing as of the date of such service or documents 1271
the organization can reasonably determine are necessary to 1272
process the claim. 1273
2. A provider must submit the additional information or 1274
documentation, as specified on the itemized list, within 30 35 1275

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days after receipt of the notification of contestation unless, 1276
within the 30-day period, the provider notifies the health 1277
maintenance organization of the provider's position that a clean 1278
claim has been submitted. Additional information is considered 1279
submitted on the date it is electronically transferred or 1280
mailed. The health maintenance organization is prohibited from 1281
requesting may not request duplicate documents. 1282
(d) For purposes of this subsection, electronic means of 1283
transmission of claims, notices, documents, forms, and payments 1284
shall be used to the greatest extent possible by the health 1285
maintenance organization and the provider. 1286
(e) A claim that was contested by the health maintenance 1287
organization must be paid or denied within 30 120 days after 1288
receipt of the additional information requested claim. Failure 1289
to pay or deny a claim within 90 140 days after receipt of the 1290
claim, regardless of whether contested by the health maintenance 1291
organization, creates an uncontestable obligation to pay the 1292
claim as submitted by the provider. 1293
(5) Regardless of whether a claim has been submitted 1294
electronically or nonelectronically, and notwithstanding any 1295
other provision of this section to the contrary: 1296
(a) Once a provider grants a health maintenance 1297
organization access to a patient's electronic medical record, 1298
the provider shall be deemed to have supplied all information 1299
necessary to pay the claim, including, without limitation, all 1300

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information that is required under the applicable billing 1301
instrument and that was reasonably required by the health 1302
maintenance organization, other than for emergency health care 1303
services, in advance of the provision of service to substantiate 1304
the claim. Additional information or documentation, regardless 1305
of whether the health maintenance organization requests any 1306
additional information, shall be deemed unnecessary, and deemed 1307
not required for payment of the claim, and any request for 1308
additional information, and any position of the health 1309
maintenance organization or any third party acting on behalf of 1310
the health maintenance organization regarding any lack of 1311
information from the provider, is prohibited from being used to 1312
deny, reduce, offset, withhold, pend, or delay payment of the 1313
claim. 1314
(b) For instances in which notice of access to the 1315
electronic medical record has been provided to the health 1316
maintenance organization, the claim must be paid or denied 1317
within 30 days of such notice to the health maintenance 1318
organization. Failure to pay or deny a claim, for which the 1319
health maintenance organization has been provided notice of 1320
access to the electronic medical record within 75 days after 1321
receipt of such notice creates an uncontestable obligation to 1322
pay the claim as submitted by the provider. 1323
(6)(5) If a health maintenance organization determines 1324
that it has made an overpayment to a provider for services 1325

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rendered to an enrollee a subscriber, the health maintenance 1326
organization must make an overpayment a claim for such 1327
overpayment to the provider's designated location. A health 1328
maintenance organization that makes an overpayment a claim for 1329
overpayment to a provider under this section shall give the 1330
provider a written or electronic statement specifying the basis 1331
for the retrospective retroactive denial or payment adjustment. 1332
The health maintenance organization must also identify the claim 1333
or claims, or overpayment claim portion thereof, as to which the 1334
health maintenance organization alleges overpayment; and the 1335
specific invoice number submitted with or on the claim, as well 1336
as the specific line items on the bill that are subject to the 1337
overpayment claim for which a claim for overpayment is 1338
submitted. Except as provided in subparagraph (a)3., there shall 1339
be no denial, reduction, offset, withholding, pending, or delay 1340
of payment, or other negative impact, regardless of whether by 1341
the health maintenance organization or any third party acting on 1342
behalf of such health maintenance organization, on payment of 1343
any other claim of the provider on the basis of the overpayment 1344
allegation. 1345
(a) If an overpayment determination is the result of 1346
retrospective retroactive review or retrospective audit of 1347
coverage decisions or payment levels not related to fraud, a 1348
health maintenance organization shall adhere to the following 1349
procedures: 1350

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1. All overpayment claims for overpayment must be received 1351
by the submitted to a provider within 18 30 months after the 1352
health maintenance organization's payment of the claim. A 1353
provider must pay, deny, or contest the health maintenance 1354
organization's overpayment claim for overpayment within 40 days 1355
after the receipt of the overpayment claim. All contested 1356
overpayment claims for overpayment must be paid or denied within 1357
120 days after receipt of the overpayment claim. Failure to pay 1358
or deny an overpayment and claim within 140 days after receipt 1359
creates an uncontestable obligation to pay the overpayment 1360
claim. 1361
2. A provider that denies or contests a health maintenance 1362
organization's overpayment claim for overpayment or any portion 1363
of an overpayment a claim shall notify the health maintenance 1364
organization, in writing, within 40 35 days after the provider 1365
receives the overpayment claim that the overpayment claim for 1366
overpayment is contested or denied. The notice that the 1367
overpayment claim for overpayment is denied or contested must 1368
identify the denied or contested portion of the claim and the 1369
specific reason for contesting or denying the overpayment claim 1370
and, if contested, must include a request for additional 1371
information. If the health maintenance organization submits 1372
additional information, the health maintenance organization 1373
must, within 35 days after receipt of the request, mail or 1374
electronically transfer the information to the provider. The 1375

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provider shall pay or deny the overpayment claim for overpayment 1376
within 45 days after receipt of the information. The notice from 1377
the provider regarding denial or contestation of the overpayment 1378
claim is considered made on the date the notice is mailed or 1379
electronically transferred by the provider. 1380
3. The health maintenance organization is prohibited from 1381
denying, reducing, offsetting, withholding, pending, or delaying 1382
may not reduce payment to the provider for other services unless 1383
the provider agrees to the denial, reduction, offset, 1384
withholding, pending, or delay of payment in writing or fails to 1385
respond to the health maintenance organization's overpayment 1386
claim as required by this paragraph. 1387
4. Payment of an overpayment claim is considered made on 1388
the date the payment was mailed or electronically transferred. 1389
An overdue payment of a claim bears simple interest at the rate 1390
of 12 percent per year. Interest on an overdue payment for an 1391
overpayment a claim for an overpayment payment begins to accrue 1392
when the overpayment claim should have been paid, denied, or 1393
contested. 1394
(b) An overpayment A claim is prohibited for overpayment 1395
shall not be permitted beyond 18 30 months after the health 1396
maintenance organization's payment of a claim, except that 1397
overpayment claims for overpayment may be sought beyond that 1398
time from providers convicted of fraud pursuant to s. 817.234. 1399
(7)(6) Payment of a claim is considered made on the date 1400

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the payment was mailed or electronically transferred to the 1401
provider. An overdue payment of a claim bears simple interest of 1402
15 12 percent per year, to be calculated upon the full total 1403
amount that should have been paid on the claim within the 1404
applicable time period specified in this section. If an 1405
applicable court, arbitration tribunal, or other binding legal 1406
process determines that a claim that was paid at a lesser amount 1407
should have been paid at a full total amount, whether under a 1408
breach of contract legal claim, a legal claim under a statutory 1409
private cause of action, or other basis, the 15 percent per year 1410
interest shall be calculated upon the full total amount, rather 1411
than upon the difference between the full total amount and the 1412
amount that was actually paid. If an applicable court, 1413
arbitration tribunal, or other binding legal process determines 1414
that a claim was subject to an inappropriate or impermissible 1415
denial or partial denial, whether in a breach of contract, 1416
statute, common law, or otherwise, interest shall be calculated 1417
upon the full total amount that should have been paid on the 1418
claim within the applicable time period for payment specified in 1419
this section, and the act of denial or partial denial shall be 1420
deemed not to have in any way tolled the time period for such 1421
payment. Interest on the full total amount that should have been 1422
paid on the claim within the applicable time period specified in 1423
this section an overdue payment for a claim or for any portion 1424
of a claim begins to accrue when the claim should have been 1425

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paid, denied, or contested. The interest must be paid along 1426
with, and in addition to, the payment for the satisfaction of 1427
the full total amount of the claim, as determined by an 1428
applicable court, arbitration tribunal, or other binding legal 1429
process is payable with the payment of the claim. 1430
(8)(7) For all contracts entered into or renewed on or 1431
after October 1, 2002, a health maintenance organization's 1432
internal dispute resolution process related to a denied claim 1433
not under active review by a mediator, arbitrator, or third-1434
party dispute entity must be finalized within 60 days after the 1435
receipt of the provider's request for review or appeal. 1436
Notwithstanding any provision of this section to the contrary, 1437
if the provider and health maintenance organization disagree as 1438
to the interpretation of contractual or statutory language, the 1439
provider is not required to participate in the health 1440
maintenance organization's internal dispute resolution process. 1441
(9)(8) A provider or any representative of a provider, 1442
regardless of whether the provider is under contract with the 1443
health maintenance organization, is prohibited from collecting 1444
or attempting may not collect or attempt to collect money from, 1445
maintaining maintain any action at law against, or reporting 1446
report to a credit agency an enrollee a subscriber for payment 1447
of covered services for which the health maintenance 1448
organization contested or denied the provider's claim. This 1449
prohibition applies during the pendency of any claim for payment 1450

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made by the provider to the health maintenance organization for 1451
payment of the services or internal dispute resolution process 1452
to determine whether the health maintenance organization is 1453
liable for the services. For a claim, this pendency applies from 1454
the date the claim or a portion of the claim is denied to the 1455
date of the completion of the health maintenance organization's 1456
internal dispute resolution process, not to exceed 60 days. This 1457
subsection does not prohibit collection by the provider of 1458
copayments, coinsurance, or deductible amounts due the provider. 1459
(9) The provisions of this section may not be waived, 1460
voided, or nullified by contract. 1461
(10) A health maintenance organization is prohibited from 1462
retrospectively denying may not retroactively deny a claim 1463
because of enrollee subscriber ineligibility more than 90 days 1 1464
year after the date of payment of the claim. 1465
(11) A health maintenance organization shall pay a 1466
contracted primary care or admitting physician, pursuant to such 1467
physician's contract, for providing inpatient services in a 1468
contracted hospital to an enrollee a subscriber if such services 1469
are determined by the primary care physician or admitting 1470
physician health maintenance organization to be medically 1471
necessary and such services are covered services under the 1472
health maintenance organization's contract with the contract 1473
holder. 1474
(12) A permissible error ratio of 5 percent is established 1475

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for health maintenance organizations' claims payment violations 1476
of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c), 1477
and (e). If the error ratio of a particular health maintenance 1478
organization insurer does not exceed the permissible error ratio 1479
of 5 percent for an audit period, no fine shall be assessed for 1480
the noted claims violations for the audit period. The error 1481
ratio shall be determined by dividing the number of claims with 1482
violations found on a statistically valid sample of claims for 1483
the audit period by the total number of claims in the sample. If 1484
the error ratio exceeds the permissible error ratio of 5 1485
percent, a fine may be assessed according to s. 624.4211 for 1486
those claims payment violations which exceed the error ratio. 1487
Notwithstanding the provisions of this section, the office may 1488
fine a health maintenance organization for claims payment 1489
violations of paragraphs (3)(e) and (4)(e) which create an 1490
uncontestable obligation to pay the claim as submitted by the 1491
provider. The office shall refrain from imposing a not fine upon 1492
a health maintenance organization organizations for violations 1493
which the office determines were due to circumstances beyond the 1494
organization's control. 1495
(13) This section shall apply to all claims or any portion 1496
of a claim submitted for payment for services provided to an 1497
enrollee by a health maintenance organization subscriber under a 1498
health maintenance organization plan, or submitted for payment 1499
for services provided to an enrollee under a self-insured plan 1500

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or fund, or fully-insured plan or fund, offered by a person or 1501
entity, when a health maintenance organization is involved in 1502
the administration, or claims-processing activities, relating to 1503
such plan or fund subscriber contract to the organization for 1504
payment. 1505
(14) Notwithstanding paragraph (3)(b), where an electronic 1506
pharmacy claim is submitted to a pharmacy benefits manager 1507
acting on behalf of a health maintenance organization, the 1508
pharmacy benefits manager shall, within 30 days after of receipt 1509
of the claim, pay the claim or notify a provider or designee if 1510
a claim is denied or contested. Notice of the health maintenance 1511
organization's action on the claim and payment of the claim is 1512
considered to be made on the date the notice or payment was 1513
received by the provider mailed or electronically transferred. 1514
(15) Notwithstanding paragraph (4)(a), effective November 1515
1, 2003, where a nonelectronic pharmacy claim is submitted to a 1516
pharmacy benefits manager acting on behalf of a health 1517
maintenance organization, the pharmacy benefits manager shall 1518
provide acknowledgment of receipt of the claim within 30 days 1519
after receipt of the claim to the provider or provide a provider 1520
within 30 days after receipt with electronic access to the 1521
status of a submitted claim. 1522
(16) Notwithstanding the 18-month 30-month period provided 1523
in subsection (6) (5), all claims for overpayment submitted to a 1524
provider licensed under chapter 395, chapter 458, chapter 459, 1525

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chapter 460, chapter 461, chapter 463, chapter 466, or chapter 1526
490 must be submitted to the provider within 12 months after the 1527
health maintenance organization's payment of the claim. An 1528
overpayment A claim to a provider licensed under chapter 395, 1529
458, chapter 459, chapter 460, chapter 461, chapter 463, chapter 1530
466, or chapter 490 is prohibited for overpayment may not be 1531
permitted beyond 12 months after the health maintenance 1532
organization's payment of a claim, except that claims for 1533
overpayment may be sought beyond that time from providers 1534
convicted of fraud pursuant to s. 817.234. 1535
(17) Notwithstanding any other provision of this section, 1536
all claims for underpayment from a provider licensed under 1537
chapter 395, chapter 458, chapter 459, chapter 460, chapter 461, 1538
or chapter 466 must be submitted to the health maintenance 1539
organization within 12 months after the health maintenance 1540
organization's payment of the claim. A claim for underpayment by 1541
a provider licensed under chapter 395, 458, chapter 459, chapter 1542
460, chapter 461, or chapter 466 is prohibited may not be 1543
permitted beyond 12 months after the health maintenance 1544
organization's payment of a claim. 1545
(18) Nothing in this section shall be interpreted to 1546
limit, restrict, or negatively impact any legal claim by a 1547
provider or health maintenance organization for breach of 1548
contract, statutory or regulatory violation, or a common-law 1549
cause of action, nor to shorten or otherwise negatively impact 1550

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the statute of limitations timeframe for bringing any such legal 1551
claim. 1552
(19) A health insurer is prohibited from requesting 1553
information from a contracted or noncontracted provider which 1554
does not apply to the medical condition at issue for the 1555
purposes of adjudicating a clean claim. 1556
(20) A health maintenance organization is prohibited from 1557
requesting a contracted or noncontracted provider to resubmit 1558
claim information that the contracted or noncontracted provider 1559
can document it has already provided to the health maintenance 1560
organization or that is contained inside the electronic medical 1561
record to which the health maintenance organization has been 1562
provided access. 1563
(21) Notwithstanding any other provision of this section 1564
to the contrary, a health maintenance organization is prohibited 1565
from requiring any information from a provider before the 1566
provision of emergency health care services as a condition of 1567
payment of a claim, as a basis for denying, delaying, 1568
offsetting, withholding, or reducing payment of a claim, or in 1569
contesting whether the claim is a clean claim. 1570
(22) In an instance of a violation of this section, a 1571
provider shall have a private cause of action to proceed against 1572
the health maintenance organization in the applicable tribunal 1573
for the violation. 1574
Section 5. Paragraph (c) of subsection (2) of section 1575

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395.1065, Florida Statutes, is amended to read: 1576
395.1065 Criminal and administrative penalties; 1577
moratorium.— 1578
(2) 1579
(c) The agency may impose an administrative fine for the 1580
violation of s. 641.3154 or, if sufficient claims due to a 1581
provider from a health maintenance organization do not exist to 1582
enable the take-back of an overpayment, as provided under s. 1583
641.3155(6) s. 641.3155(5), for the violation of s. 641.3155(5) 1584
s. 641.3155(5). The administrative fine for a violation cited in 1585
this paragraph shall be in the amounts specified in s. 1586
641.52(5), and the provisions of paragraph (a) do not apply. 1587
Section 6. This act shall take effect July 1, 2026. 1588