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HB 1023 2026
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to insurance claims payments to health 2
care providers; amending s. 408.7057, F.S.; defining 3
the terms "claim dispute" and "denied prior 4
authorization request"; requiring the Agency for 5
Health Care Administration to establish a program to 6
assist health care providers and health plans in 7
resolving claims of denied prior authorization 8
requests; providing that the program is mandatory; 9
revising the list of claims that are not reviewed by 10
the program; prohibiting respondents from avoiding 11
default by refusing to participate in the review 12
process; requiring health plans to reimburse health 13
care providers' costs in bringing claims under certain 14
circumstances; requiring the agency to adopt rules; 15
amending ss. 627.6131 and 641.315, F.S.; prohibiting 16
contracts between health care providers and health 17
insurers and health maintenance organizations, 18
respectively, from specifying credit card payments to 19
providers as the only acceptable method for payments; 20
authorizing use of electronic funds transfers by 21
health insurers and health maintenance organizations, 22
respectively, for payments to providers under certain 23
circumstances; providing notification requirements; 24
prohibiting health insurers and health maintenance 25
HB 1023 2026
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organizations, respectively, from charging fees for 26
automated clearinghouse transfers as claims payments 27
to providers; providing an exception; providing 28
applicability; prohibiting health insurers and health 29
maintenance organizations, respectively, from denying 30
claims subsequently submitted by providers for 31
procedures that were included in prior authorizations; 32
providing exceptions; providing applicability; 33
defining the term "provider"; providing an effective 34
date. 35
36
Be It Enacted by the Legislature of the State of Florida: 37
38
Section 1. Section 408.7057, Florida Statutes, is amended 39
to read: 40
408.7057 Statewide provider and health plan claim dispute 41
resolution program.— 42
(1) As used in this section, the term: 43
(a) "Agency" means the Agency for Health Care 44
Administration. 45
(b) "Claim dispute" may include, but is not limited to, a 46
denied prior authorization request. 47
(c) "Denied prior authorization request" means a 48
determination by a health plan that a request submitted by a 49
provider for prior authorization of a health care service, 50
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supply, or medication: 51
1. Has been wholly or partially denied; 52
2. Has not been acted upon within the time limits 53
established by law or contract; or 54
3. Has been approved subject to materially restrictive 55
conditions that prevent the service, supply, or medication from 56
being furnished as clinically indicated. 57
(d)(b) "Health plan" means a health maintenance 58
organization or a prepaid health clinic certified under chapter 59
641, a prepaid health plan authorized under s. 409.912, an 60
exclusive provider organization certified under s. 627.6472, or 61
a major medical expense health insurance policy, as defined in 62
s. 627.643(2)(e), offered by a group or an individual health 63
insurer licensed pursuant to chapter 624, including a preferred 64
provider organization under s. 627.6471. 65
(e)(c) "Resolution organization" means a qualified 66
independent third-party claim-dispute-resolution entity selected 67
by and contracted with the Agency for Health Care 68
Administration. 69
(2)(a) The agency shall establish a program to provide 70
assistance to contracted and noncontracted providers and health 71
plans for resolution of claim disputes that are not resolved by 72
the provider and the health plan. The agency shall contract with 73
a resolution organization to timely review and consider claim 74
disputes submitted by providers and health plans and recommend 75
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to the agency an appropriate resolution of those disputes. The 76
agency shall establish by rule jurisdictional amounts and 77
methods of aggregation for claim disputes that may be considered 78
by the resolution organization. 79
(b) The dispute resolution program is a mandatory program, 80
and a provider or health plan may not opt out of the process. 81
The resolution organization shall review claim disputes filed by 82
contracted and noncontracted providers and health plans unless 83
the disputed claim: 84
1. Is related to interest payment; 85
2. Does not meet the jurisdictional amounts or the methods 86
of aggregation established by agency rule, as provided in 87
paragraph (a); 88
3. Is part of an internal grievance in a Medicare managed 89
care organization or a reconsideration appeal through the 90
Medicare appeals process; 91
4. Is related to a health plan that is not regulated by 92
the state; 93
5. Is part of a Medicaid fair hearing pursued under 42 94
C.F.R. ss. 431.220 et seq.; 95
6. Is the specific subject of an existing lawsuit filed 96
basis for an action pending in state or federal court before the 97
submission of the claim to the resolution organization; or 98
7. Is subject to a binding claim-dispute-resolution 99
process provided by contract entered into prior to October 1, 100
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2000, between the provider and the managed care organization. 101
(c) Contracts entered into or renewed on or after October 102
1, 2000, may require exhaustion of an internal dispute-103
resolution process as a prerequisite to the submission of a 104
claim by a provider or a health plan to the resolution 105
organization. 106
(d) A contracted or noncontracted provider or health plan 107
may not file a claim dispute with the resolution organization 108
more than 12 months after a final determination has been made on 109
a claim by a health plan or provider. 110
(e) The resolution organization shall require the health 111
plan or provider submitting the claim dispute to submit any 112
supporting documentation to the resolution organization within 113
15 days after receipt by the health plan or provider of a 114
request from the resolution organization for documentation in 115
support of the claim dispute. The resolution organization may 116
extend the time if appropriate. Failure to submit the supporting 117
documentation within such time period shall result in the 118
dismissal of the submitted claim dispute. 119
(f) The resolution organization shall require the 120
respondent in the claim dispute to submit all documentation in 121
support of its position within 15 days after receiving a request 122
from the resolution organization for supporting documentation. 123
The resolution organization may extend the time if appropriate. 124
Failure to submit the supporting documentation within such time 125
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period shall result in a default against the health plan or 126
provider. The respondent may not avoid default by declining to 127
participate in the review process provided in this section. In 128
the event of such a default, the resolution organization shall 129
issue its written recommendation to the agency that a default be 130
entered against the defaulting entity. The written 131
recommendation shall include a recommendation to the agency that 132
the defaulting entity shall pay the entity submitting the claim 133
dispute the full amount of the claim dispute, plus all accrued 134
interest, and shall be considered a nonprevailing party for the 135
purposes of this section. 136
(g)1. If on an ongoing basis during the preceding 12 137
months, the agency has reason to believe that a pattern of 138
noncompliance with s. 627.6131 and s. 641.3155 exists on the 139
part of a particular health plan or provider, the agency shall 140
evaluate the information contained in these cases to determine 141
whether the information evidences a pattern and report its 142
findings, together with substantiating evidence, to the 143
appropriate licensure or certification entity for the health 144
plan or provider. 145
2. In addition, the agency shall prepare a report to the 146
Governor and the Legislature by February 1 of each year, 147
enumerating: claims dismissed; defaults issued; and failures to 148
comply with agency final orders issued under this section. 149
(h) Either the contracted or noncontracted provider or the 150
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health plan may make an offer to settle the claim dispute when 151
it submits a request for a claim dispute and supporting 152
documentation. The offer to settle the claim dispute must state 153
its total amount, and the party to whom it is directed has 15 154
days to accept the offer once it is received. If the party 155
receiving the offer does not accept the offer and the final 156
order amount is more than 90 percent or less than 110 percent of 157
the offer amount, the party receiving the offer must pay the 158
final order amount to the offering party and is deemed a 159
nonprevailing party for purposes of this section. The amount of 160
an offer made by a contracted or noncontracted provider to 161
settle an alleged underpayment by the health plan must be 162
greater than 110 percent of the reimbursement amount the 163
provider received. The amount of an offer made by a health plan 164
to settle an alleged overpayment to the provider must be less 165
than 90 percent of the alleged overpayment amount by the health 166
plan. Both parties may agree to settle the disputed claim at any 167
time, for any amount, regardless of whether an offer to settle 168
was made or rejected. 169
(3) The agency shall adopt rules to establish a process to 170
be used by the resolution organization in considering claim 171
disputes submitted by a provider or health plan which must 172
include: 173
(a) That the resolution organization review and consider 174
all documentation submitted by both the health plan and the 175
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provider; 176
(b) That the resolution organization's recommendation make 177
findings of fact; 178
(c) That either party may request that the resolution 179
organization conduct an evidentiary hearing in which both sides 180
can present evidence and examine witnesses, and for which the 181
cost of the hearing is equally shared by the parties; 182
(d) That the resolution organization may not communicate 183
ex parte with either the health plan or the provider during the 184
dispute resolution; 185
(e) That the resolution organization's written 186
recommendation, including findings of fact relating to the 187
calculation under s. 641.513(5) for the recommended amount due 188
for the disputed claim, include any evidence relied upon; and 189
(f) That the resolution organization issue a written 190
recommendation to the agency within 60 days after the requested 191
information is received by the resolution organization within 192
the timeframes specified by the resolution organization. In no 193
event shall the review time exceed 90 days following receipt of 194
the initial claim dispute submission by the resolution 195
organization. 196
(4) Within 30 days after receipt of the recommendation of 197
the resolution organization, the agency shall adopt the 198
recommendation as a final order. The final order is subject to 199
judicial review pursuant to s. 120.68. 200
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(5) The agency shall notify within 7 days the appropriate 201
licensure or certification entity whenever there is a violation 202
of a final order issued by the agency pursuant to this section. 203
(6) The entity that does not prevail in the agency's order 204
must pay a review cost to the review organization, as determined 205
by agency rule. Such rule must provide for an apportionment of 206
the review fee in any case in which both parties prevail in 207
part. If the nonprevailing party fails to pay the ordered review 208
cost within 35 days after the agency's order, the nonpaying 209
party is subject to a penalty of not more than $500 per day 210
until the penalty is paid. 211
(7) If a claim dispute under this section involves a 212
denied prior authorization request and the health plan is 213
determined to be the nonprevailing party, the health plan shall 214
reimburse the provider for the provider's reasonable costs 215
incurred in bringing the claim, including any filing fees and 216
administrative costs assessed by the agency or its designee. The 217
agency shall adopt rules to specify allowable costs and 218
procedures for cost recovery under this subsection. 219
(8)(7) The agency may adopt rules to administer this 220
section. 221
Section 2. Subsections (20) and (21) of section 627.6131, 222
Florida Statutes, are amended to read: 223
627.6131 Payment of claims.— 224
(20)(a) A contract between a health insurer and a dentist 225
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licensed under chapter 466 or a provider for the provision of 226
services to an insured may not specify credit card payment as 227
the only acceptable method for payments from the health insurer 228
to the dentist or provider. 229
(b) When a health insurer employs the method of claims 230
payment to a dentist or provider through electronic funds 231
transfer, including, but not limited to, virtual credit card 232
payment, the health insurer shall notify the dentist or provider 233
as provided in this paragraph and obtain the dentist's or 234
provider's consent before employing the electronic funds 235
transfer. The dentist's or provider's consent described in this 236
paragraph applies to the dentist's or provider's entire 237
practice. For the purpose of this paragraph, the dentist's or 238
provider's consent, which may be given through e-mail, must bear 239
the signature of the dentist or provider. Such signature 240
includes an electronic or digital signature if the form of 241
signature is recognized as a valid signature under applicable 242
federal law or state contract law or an act that demonstrates 243
express consent, including, but not limited to, checking a box 244
indicating consent. The health insurer or the dentist or 245
provider may not require that a dentist's or provider's consent 246
as described in this paragraph be made on a patient-by-patient 247
basis. The notification provided by the health insurer to the 248
dentist or provider must include all of the following: 249
1. The fees, if any, associated with the electronic funds 250
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transfer. 251
2. The available methods of payment of claims by the 252
health insurer, with clear instructions to the dentist or 253
provider on how to select an alternative payment method. 254
(c) A health insurer that pays a claim to a dentist or 255
provider through automated clearinghouse transfer may not charge 256
a fee solely to transmit the payment to the dentist or provider 257
unless the dentist or provider has consented to the fee. 258
(d) This subsection applies to all contracts: 259
1. Between a health insurer and a dentist which are 260
delivered, issued, or renewed on or after January 1, 2025. 261
2. Between a health insurer and a provider which are 262
delivered, issued, or renewed on or after January 1, 2027. 263
(e) The office has all rights and powers to enforce this 264
subsection as provided by s. 624.307. 265
(f) The commission may adopt rules to implement this 266
subsection. 267
(g) As used in this subsection, the term "provider" has 268
the same meaning as the term "health care provider" in s. 269
381.00321(1). 270
(21)(a) A health insurer may not deny any claim 271
subsequently submitted by a dentist licensed under chapter 466 272
or a provider for procedures specifically included in a prior 273
authorization unless at least one of the following circumstances 274
applies for each procedure denied: 275
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1. Benefit limitations, such as annual maximums and 276
frequency limitations not applicable at the time of the prior 277
authorization, are reached subsequent to issuance of the prior 278
authorization. 279
2. The documentation provided by the person submitting the 280
claim fails to support the claim as originally authorized. 281
3. Subsequent to the issuance of the prior authorization, 282
new procedures are provided to the patient or a change in the 283
condition of the patient occurs such that the prior authorized 284
procedure would no longer be considered medically necessary, 285
based on the prevailing standard of care. 286
4. Subsequent to the issuance of the prior authorization, 287
new procedures are provided to the patient or a change in the 288
patient's condition occurs such that the prior authorized 289
procedure would at that time have required disapproval pursuant 290
to the terms and conditions for coverage under the patient's 291
plan in effect at the time the prior authorization was issued. 292
5. The denial of the claim was due to one of the 293
following: 294
a. Another payor is responsible for payment. 295
b. The dentist or provider has already been paid for the 296
procedures identified in the claim. 297
c. The claim was submitted fraudulently, or the prior 298
authorization was based in whole or material part on erroneous 299
information provided to the health insurer by the dentist or 300
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provider, patient, or other person not related to the insurer. 301
d. The person receiving the procedure was not eligible to 302
receive the procedure on the date of service. 303
e. The services were provided during the grace period 304
established under s. 627.608 or applicable federal regulations, 305
and the dental insurer notified the dentist or provider that the 306
patient was in the grace period when the dentist or provider 307
requested eligibility or enrollment verification from the dental 308
insurer, if such request was made. 309
(b) This subsection applies to all contracts: 310
1. Between a health insurer and a dentist which are 311
delivered, issued, or renewed on or after January 1, 2025. 312
2. Between a health insurer and a provider which are 313
delivered, issued, or renewed on or after January 1, 2027. 314
(c) The office has all rights and powers to enforce this 315
subsection as provided by s. 624.307. 316
(d) The commission may adopt rules to implement this 317
subsection. 318
(e) As used in this subsection, the term "provider" has 319
the same meaning as the term "health care provider" in s. 320
381.00321(1). 321
Section 3. Subsections (13) and (14) of section 641.315, 322
Florida Statutes, are amended to read: 323
641.315 Provider contracts.— 324
(13)(a) A contract between a health maintenance 325
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organization and a dentist licensed under chapter 466 or a 326
provider for the provision of services to a subscriber of the 327
health maintenance organization may not specify credit card 328
payment as the only acceptable method for payments from the 329
health maintenance organization to the dentist or provider. 330
(b) When a health maintenance organization employs the 331
method of claims payment to a dentist or provider through 332
electronic funds transfer, including, but not limited to, 333
virtual credit card payment, the health maintenance organization 334
shall notify the dentist or provider as provided in this 335
paragraph and obtain the dentist's or provider's consent before 336
employing the electronic funds transfer. The dentist's or 337
provider's consent described in this paragraph applies to the 338
dentist's or provider's entire practice. For the purpose of this 339
paragraph, the dentist's or provider's consent, which may be 340
given through e-mail, must bear the signature of the dentist or 341
provider. Such signature includes an electronic or digital 342
signature if the form of signature is recognized as a valid 343
signature under applicable federal law or state contract law or 344
an act that demonstrates express consent, including, but not 345
limited to, checking a box indicating consent. The health 346
maintenance organization or the dentist or provider may not 347
require that a dentist's or provider's consent as described in 348
this paragraph be made on a patient-by-patient basis. The 349
notification provided by the health maintenance organization to 350
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the dentist or provider must include all of the following: 351
1. The fees, if any, that are associated with the 352
electronic funds transfer. 353
2. The available methods of payment of claims by the 354
health maintenance organization, with clear instructions to the 355
dentist or provider on how to select an alternative payment 356
method. 357
(c) A health maintenance organization that pays a claim to 358
a dentist or provider through automated clearinghouse Clearing 359
House transfer may not charge a fee solely to transmit the 360
payment to the dentist or provider unless the dentist or 361
provider has consented to the fee. 362
(d) This subsection applies to all contracts: 363
1. Between a health maintenance organization and a dentist 364
which are delivered, issued, or renewed on or after January 1, 365
2025. 366
2. Between a health maintenance organization and a 367
provider which are delivered, issued, or renewed on or after 368
January 1, 2027. 369
(e) The office has all rights and powers to enforce this 370
subsection as provided by s. 624.307. 371
(f) The commission may adopt rules to implement this 372
subsection. 373
(g) As used in this subsection, the term "provider" has 374
the same meaning as the term "health care provider" in s. 375
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381.00321(1). 376
(14)(a) A health maintenance organization may not deny any 377
claim subsequently submitted by a dentist licensed under chapter 378
466 or a provider licensed for procedures specifically included 379
in a prior authorization unless at least one of the following 380
circumstances applies for each procedure denied: 381
1. Benefit limitations, such as annual maximums and 382
frequency limitations not applicable at the time of the prior 383
authorization, are reached subsequent to issuance of the prior 384
authorization. 385
2. The documentation provided by the person submitting the 386
claim fails to support the claim as originally authorized. 387
3. Subsequent to the issuance of the prior authorization, 388
new procedures are provided to the patient or a change in the 389
condition of the patient occurs such that the prior authorized 390
procedure would no longer be considered medically necessary, 391
based on the prevailing standard of care. 392
4. Subsequent to the issuance of the prior authorization, 393
new procedures are provided to the patient or a change in the 394
patient's condition occurs such that the prior authorized 395
procedure would at that time have required disapproval pursuant 396
to the terms and conditions for coverage under the patient's 397
plan in effect at the time the prior authorization was issued. 398
5. The denial of the claim was due to one of the 399
following: 400
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a. Another payor is responsible for payment. 401
b. The dentist or provider has already been paid for the 402
procedures identified in the claim. 403
c. The claim was submitted fraudulently, or the prior 404
authorization was based in whole or material part on erroneous 405
information provided to the health maintenance organization by 406
the dentist or provider, patient, or other person not related to 407
the organization. 408
d. The person receiving the procedure was not eligible to 409
receive the procedure on the date of service. 410
e. The services were provided during the grace period 411
established under s. 627.608 or applicable federal regulations, 412
and the health maintenance organization dental insurer notified 413
the dentist or provider that the patient was in the grace period 414
when the dentist or provider requested eligibility or enrollment 415
verification from the health maintenance organization dental 416
insurer, if such request was made. 417
(b) This subsection applies to all contracts: 418
1. Between a health maintenance organization and a dentist 419
which are delivered, issued, or renewed on or after January 1, 420
2025. 421
2. Between a health maintenance organization and a 422
provider which are delivered, issued, or renewed on or after 423
January 1, 2027. 424
(c) The office has all rights and powers to enforce this 425
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subsection as provided by s. 624.307. 426
(d) The commission may adopt rules to implement this 427
subsection. 428
(e) As used in this subsection, the term "provider" has 429
the same meaning as the term "health care provider" in s. 430
381.00321(1). 431
Section 4. This act shall take effect July 1, 2026. 432