Insurance Claims Payments to Health Care Providers

Florida Senate
-
2026

SB 1130

By
Senator Massullo

11-00698A-26 20261130__
1 A bill to be entitled
2 An act relating to insurance claims payments to health
3 care providers; creating s. 627.4193, F.S.; defining
4 terms; prohibiting payment adjudicators from
5 downcoding health care services under certain
6 circumstances; providing exceptions; requiring payment
7 adjudicators to provide certain information to the
8 provider; prohibiting payment adjudicators from
9 downcoding a service under certain circumstances;
10 prohibiting payment adjudicators for downcoding orders
11 by a licensed nurse; specifying that payment
12 adjudicators are solely responsible for certain
13 violations of law; requiring payment adjudicators to
14 maintain downcoding policies on their websites;
15 specifying requirements for such policies; requiring
16 health insurers to ensure that their downcoding
17 policies are updated and to ensure compliance with
18 specified provisions on downcoding; authorizing
19 investigations and actions against noncompliance;
20 providing certain presumption in favor of physicians’
21 determinations regarding diagnoses of patients and
22 service orders; providing the calculation of interest
23 on health insurers’ nonpayment or underpayment due to
24 downcoding; providing a cause of action for health
25 care providers; amending s. 627.42392, F.S.; defining
26 terms; revising the definition of the term “health
27 insurer”; requiring certain utilization review
28 entities to only use a certain prior authorization
29 form; deleting provisions related to pharmacy benefits
30 managers’ or health insurers’ requirement to use a
31 specified prior authorization form; requiring
32 utilization review entities to establish and offer a
33 specified electronic prior authorization process;
34 specifying requirements for such process; specifying
35 that the provider is deemed to have supplied all
36 information necessary for prior authorization under
37 certain circumstances; specifying that additional
38 information is deemed unnecessary under certain
39 circumstances; prohibiting utilization review
40 entities’ prior authorization process from requiring
41 information that is not needed; requiring utilization
42 review entities to disclose all prior authorization
43 requirements and restrictions; requiring such
44 requirements and restrictions to be explained in a
45 specified manner; prohibiting utilization review
46 entities from implementing certain new requirements or
47 restrictions; providing exceptions; providing
48 reporting requirements; requiring the Office of
49 Insurance Regulation to publish on its website a
50 report based on such entities’ reports; providing
51 requirements for adverse determinations made by such
52 entities on health care providers’ claims; providing a
53 timeframe for such entities’ determination on claims;
54 prohibiting prior authorization requirements under
55 certain circumstances; prohibiting prior authorization
56 revocations, limits, conditions, and restrictions
57 under certain circumstances; providing exceptions;
58 providing a timeframe for the validity of prior
59 authorizations under certain circumstances; providing
60 construction; amending ss. 627.6131 and 641.3155,
61 F.S.; defining terms; revising the definition of the
62 term “claim”; revising requirements and timeframes for
63 responses from health insurers and health maintenance
64 organizations, respectively, to submitted claims;
65 revising the interest rate on overdue payments of
66 claims; authorizing health care providers to refuse to
67 participate in internal dispute resolution processes
68 under certain circumstances; prohibiting health
69 insurers and health maintenance organizations,
70 respectively, from retrospectively, rather than
71 retroactively, denying claims because of insured and
72 enrollee ineligibility beyond a specified timeframe;
73 revising such timeframe; revising applicability;
74 providing construction; prohibiting health insurers
75 and health maintenance organizations, respectively,
76 from requesting or requiring certain information from
77 health care providers under certain circumstances;
78 providing causes of action for health care providers
79 under certain circumstances; amending s. 395.1065,
80 F.S.; conforming cross-references; providing an
81 effective date.
82
83 Be It Enacted by the Legislature of the State of Florida:
84
85 Section 1. Section 627.4193, Florida Statutes, is created
86 to read:
87
627.4193

Restrictions on health insurance reimbursement

88
downcoding.—

89
(1)

As used in this section, the term:

90
(a)

“Downcode” or “downcoding” means the alteration by a

91
payment adjudicator of a service code to another service code or

92
the alteration, addition, or deletion by a payment adjudicator

93
of a modifier, when the changed code or modifier is associated

94
with a lower payment amount than the service code or modifier

95
billed by the provider or facility.

96
(b)

“Health insurer” means any entity that offers health

97
insurance coverage, whether through a fully insured plan or

98
self-insured plan or fund, including, as applicable:

99
1.

An authorized health insurer offering health insurance

100
as defined in s. 624.603, as well as any entity that offers a

101
commercial self-insurance fund as defined in s. 624.462(2) or

102
group self-insurance fund as described in s. 624.4621.

103
2.

A health insurer that is subject to any provision of

104
this chapter, as well as any entity that offers a self-insurance

105
plan or a group self-insurance plan.

106
3.

A managed care plan as defined in s. 409.962.

107
4.

A health maintenance organization as defined in s.

108
641.19.

109
(c)

“Medical record” means the comprehensive collection of

110
documentation, including clinical notes, diagnostic reports, and

111
other relevant information, which supports the health care

112
services provided.

113
(d) “Participation agreement” means a written contract or

114
agreement between a health insurer and a provider which outlines

115
the terms and conditions of participation, reimbursement rates,

116
and other relevant details.

117
(e)

“Payment adjudicator” means a health insurer or any

118
entity that provides, offers to provide, or administers payment

119
on behalf of a health insurer, as well any pharmacy benefit

120
manager as defined in s. 624.490(1), and any other individual or

121
entity that provides, offers to provide, or administers payment

122
for hospital services, outpatient services, medical services,

123
prescription drugs, or other health care services to a person

124
treated by a health care professional or facility in this state

125
under a policy, plan, or contract.

126
(f)

“Provider” means any health care professional,

127
facility, or entity that submits claims for reimbursement for

128
covered health care services.

129
(2)

Payment adjudicators are prohibited from downcoding a

130
health care service billed by, or on behalf of, a provider, if

131
the health care service was ordered by a provider that is in

132
network with the applicable health insurer, unless such

133
downcoding is otherwise expressly permitted under the

134
participation agreement between the health insurer and the

135
provider.

136
(3)

If downcoding is expressly permitted under the

137
participation agreement, the payment adjudicator must provide

138
the following information to the provider before making its

139
initial payment or notice of denial of payment:

140
(a)

A statement indicating that the service code or

141
modifier billed by the provider or facility will be downcoded.

142
(b)

An explanation detailing the reasons for downcoding the

143
claim. This explanation must include a clear description of the

144
service codes or modifiers that were altered, added, or deleted,

145
if applicable.

146
(c)

The payment amount that the payment adjudicator would

147
otherwise make if the service code or modifier is not downcoded.

148
(d)

A statement that the provider may contest the

149
downcoding of the applicable service code or modifier by filing

150
a contestation with the payment adjudicator with respect to the

151
downcoding within 15 days after receipt of the notice of

152
downcoding.

153
(e)

A statement that by contesting the downcoding of the

154
applicable service code or modifier, the provider does not waive

155
any of its legal rights and claims against the health insurer or

156
payment adjudicator to the fullest extent permissible under law.

157
(4)

Even if the participation agreement expressly permits

158
downcoding, a payment adjudicator is prohibited from downcoding

159
a service without first conducting a review of the associated

160
medical record to ensure the accuracy of the coding change.

161
(5)

A payment adjudicator is prohibited from downcoding for

162
orders by a licensed nurse.

163
(6)

Notwithstanding any provision in this section, a

164
payment adjudicator that proceeds to downcode a service code or

165
modifier, regardless of whether such downcoding is contested by

166
the provider, is solely responsible for any violations of law

167
associated with such downcoding.

168
(7)

Payment adjudicators are required to maintain clear and

169
accessible downcoding policies on their official website. These

170
policies must include:

171
(a)

An overview of the circumstances under which downcoding

172
may occur.

173
(b)

The process and criteria used for conducting reviews of

174
downcoded claims, including the role of medical record review.

175
(c)

Information about the internal mechanisms for ensuring

176
consistency and accuracy in downcoding practices.

177
(d)

Information regarding the processes for contesting with

178
the payment adjudicator the downcoding of a service code, which

179
processes must offer appeal rights for the provider and the

180
patient, and peer review by a licensed physician before the

181
downcoding.

182
(8)

Health insurers shall ensure that their downcoding

183
policies are updated as needed to reflect any changes in

184
regulations, industry standards, or internal procedures.

185
(9)

Health insurers shall ensure compliance with this

186
section and shall develop internal procedures to implement and

187
adhere to the requirements outlined in this section.

188
(10)

Regulatory authorities, including, but not limited to,

189
the Office of Insurance Regulation, may investigate and take

190
appropriate actions in cases of noncompliance with this section.

191
(11)

When a particular health care service is ordered by a

192
licensed physician, there is a presumption that the physician’s

193
determination regarding the diagnosis of the patient and any

194
service order by the physician is correct and sufficient, absent

195
a coding error which the health insurer must first verify with

196
the physician before downcoding for such error.

197
(12)

If an applicable court, arbitration tribunal, or other

198
binding legal process determines that a claim was subject to an

199
inappropriate or impermissible downcoding, whether in breach of

200
contract, statute, common law, or otherwise, such that

201
nonpayment or underpayment of the original claim has occurred,

202
then in accordance with s. 627.6131, interest must be calculated

203
on the full total amount that should have been paid on the claim

204
as of the applicable time period for payment specified in s.

205
627.6131.

206
(13)

For a violation of this section, a provider shall have

207
a private cause of action to proceed against the health insurer

208
or payment adjudicator in the applicable tribunal for the

209
violation.

210 Section 2. Section 627.42392, Florida Statutes, is amended
211 to read:
212 627.42392 Prior authorization.—
213 (1) As used in this section, the term
:

214
(a)

“Adverse determination” means a decision by a health

215
insurer or utilization review entity that the health care

216
services rendered, or proposed to be rendered, to a patient are

217
denied, reduced, or terminated. The term does not include a

218
decision to deny, reduce, or terminate services that are

219
determined to have been billed in duplicate bills or that are

220
confirmed with the provider to have been billed in error.

221
(b)

“Electronic prior authorization process” does not

222
include transmissions through a facsimile machine.

223
(c)

“Emergency health care service” means medical

224
screening, examination, and evaluation by a physician, or, to

225
the extent permitted by applicable law, by other appropriate

226
personnel under the supervision of a physician, to determine

227
whether an emergency medical condition exists and, if it does,

228
the care, treatment, or surgery by a physician necessary to

229
relieve or eliminate the emergency medical condition, within the

230
service capability of the facility.

231
(d)

“Emergency medical condition” means a medical condition

232
manifesting itself by acute symptoms of sufficient severity,

233
including severe pain, such that a prudent layperson who

234
possesses an average knowledge of health and medicine could

235
reasonably expect the absence of immediate medical attention to

236
result in any of the conditions listed in s. 395.002(8).

237
(e)

“Health insurer” means any entity that offers health

238
insurance coverage, whether through a fully insured plan or

239
self-insured plan or fund, including, as applicable:

240
1.

An authorized health insurer offering health insurance

241
as defined in s. 624.603, as well as any entity that offers a

242
commercial self-insurance fund as defined in s. 624.462(2) or a

243
group self-insurance fund as described in s. 624.4621.

244
2.

A health insurer that is subject to any provision of

245
this chapter, as well as any entity that offers a self-insurance

246
plan or a group self-insurance plan.

247
3.

A managed care plan as defined in s. 409.962.

248
4.

A health maintenance organization as defined in s.

249
641.19.

250
(f)

“Prior authorization” means the process by which

251
utilization review entities determine the medical necessity or

252
medical appropriateness of otherwise covered health care

253
services before the rendering of such health care services. The

254
term also includes any requirement by a health insurer or

255
utilization review entity that an enrollee or a health care

256
provider notify the health insurer or utilization review entity

257
before the provision of a health care service.

258
(g)

“Urgent health care service” means a health care

259
service that, if the timeframe for making a nonexpedited prior

260
authorization is applied, could, in the opinion of a physician

261
with knowledge of the patient’s medical condition:

262
1.

Seriously jeopardize the life or health of the patient

263
or the ability of the patient to regain maximum function; or

264
2.

Subject the patient to severe pain that cannot be

265
adequately managed without the care, treatment, or prescription

266
drugs that are the subject of the prior authorization request.

267
(h)

“Utilization review activity” means any activity

268
prospective to, concurrent with, or retrospective to the

269
provision of a nonemergency health care service, to determine

270
whether payment must be made in full or is subject to an adverse

271
determination. Utilization review activity is prohibited:

272
1.

To the extent restricted or prohibited by an agreement

273
with a health care provider;

274
2.

For an emergency health care service; or

275
3.

For a service provided to a patient experiencing an

276
emergency medical condition.

277
(i)

“Utilization review entity” means an entity permitted

278
under the applicable agreement with a health care provider or

279
otherwise permitted by a provider that does not have such an

280
agreement to perform utilization review activities or upon whose

281
behalf utilization review activities are performed, including,

282
as applicable:

283
1.

An authorized health insurer offering health insurance

284
as defined in s. 624.603, as well as any entity that offers a

285
commercial self-insurance fund as defined in s. 624.462(2) or

286
group self-insurance fund as described in s. 624.4621.

287
2.

A health insurer that is subject to any provision of

288
this chapter, as well as any entity that offers a self-insurance

289
plan or a group self-insurance plan.

290
3.

A managed care plan as defined in s. 409.962.

291
4.

A health maintenance organization as defined in s.

292
641.19.

293
5.

A pharmacy benefit manager as defined in s. 624.490(1).

294
6.

Any other individual or entity that provides, offers to

295
provide, or administers payment for hospital services,

296
outpatient services, medical services, prescription drugs, or

297
other health care services to a person treated by a health care

298
professional or facility in this state under a policy, plan,

299
contract, or fund

“health insurer” means an authorized insurer

300
offering health insurance as defined in s. 624.603, a managed

301
care plan as defined in s. 409.962(10), or a health maintenance

302
organization as defined in s. 641.19(12)
.
303 (2) Notwithstanding any other provision of law,
a

304
utilization review entity that

effective January 1, 2017, or six

305
(6) months after the effective date of the rule adopting the

306
prior authorization form, whichever is later, a health insurer,

307
or a pharmacy benefits manager on behalf of the health insurer,

308
which
does not provide an electronic prior authorization process
309 for use by its contracted providers
may
,
shall
only use the
310 prior authorization form that has been approved by the Financial
311 Services Commission for granting a prior authorization for a
312 medical procedure, course of treatment, or prescription drug
313 benefit. Such form
must be no longer than

may not exceed
two
314 pages in length, excluding any instructions or guiding
315 documentation, and must include all clinical documentation
316 necessary for the
utilization review entity

health insurer
to
317 make a decision. At a minimum, the form must include
:
(1)

318 sufficient patient information to identify the member, date of
319 birth, full name, and Health Plan ID number;
(2)
provider name,
320 address and phone number;
(3)
the medical procedure, course of
321 treatment, or prescription drug benefit being requested,
322 including the medical reason therefor, and all services tried
323 and failed;
(4)
any laboratory documentation required; and
(5)

324 an attestation that all information provided is true and
325 accurate.
326 (3) The Financial Services Commission
,
in consultation with
327 the Agency for Health Care Administration
,
shall adopt by rule
328 guidelines for all prior authorization forms which ensure the
329 general uniformity of such forms.
330
(4)

A utilization review entity shall establish and offer a

331
secure, interactive online electronic prior authorization

332
process to accept electronic prior authorization requests. The

333
electronic prior authorization process must allow a person

334
seeking a prior authorization the ability to upload

335
documentation if such documentation is required by the

336
utilization review entity to adjudicate the prior authorization

337
request. Once a provider grants a health insurer access to a

338
patient’s electronic medical record, the provider is deemed to

339
have supplied all information necessary for prior authorization

340
of the health care service, including, without limitation, all

341
information that is reasonably required by the health insurer,

342
other than for an emergency health care service or for a service

343
provided to a patient who is experiencing an emergency medical

344
condition, in advance of the provision of service, and the

345
health insurer asserts is missing as of the date of such

346
service. Additional information or documentation, regardless of

347
whether the utilization review entity requests any additional

348
information, is deemed unnecessary, and deemed not required, for

349
prior authorization of the health care service, and any request

350
for additional information or any position of the utilization

351
review entity or any third party acting on behalf of the

352
utilization review entity regarding any lack of information from

353
the provider is prohibited from being used to deny, pend, or

354
delay prior authorization of the health care service.

355
(5)
(4)
Electronic prior authorization approvals do not
356 preclude benefit verification or medical review by the
health

357 insurer under either the medical or pharmacy benefits.
358
(6)

A utilization review entity’s prior authorization

359
process is prohibited from requiring information that is not

360
needed to make a determination or facilitate a determination of

361
medical necessity of the requested medical procedure, course of

362
treatment, or prescription drug benefit.

363
(7)

A utilization review entity shall disclose all of its

364
prior authorization requirements and restrictions, including any

365
written clinical criteria, in a publicly accessible manner on

366
its website. These requirements and restrictions must be

367
explained in detail and in clear and ordinary terms.

368
(8)

A utilization review entity is prohibited from

369
implementing any new requirements or restrictions and from

370
making changes to existing requirements or restrictions on

371
obtaining prior authorization unless:

372
(a)

The changes have been available on a publicly

373
accessible website for at least 60 days before they are

374
implemented;

375
(b)

Policyholders and health care providers affected by the

376
new requirements and restrictions or changes to the requirements

377
and restrictions are provided with a written notice of the

378
changes at least 60 days before they are implemented, with such

379
notice being delivered electronically or by other means as

380
agreed to by the policyholder or the health care provider; and

381
(c)

All applicable amendments to a provider’s agreement

382
with the applicable health insurer or utilization review entity

383
have been obtained and memorialized in a mutually agreed-upon

384
writing before such implementation.

385
(9)(a)

Utilization review entities shall, by March 31 of

386
each year, submit a report to the Office of Insurance Regulation

387
with the following data elements for the prior calendar year:

388
1.

A list of all items and services requiring prior

389
authorization.

390
2.

The percentage of standard prior authorization requests

391
approved by the utilization review entity, aggregated by item or

392
service.

393
3.

The percentage of standard prior authorization requests

394
denied by the utilization review entity, aggregated by item or

395
service.

396
4.

The percentage of standard prior authorization requests

397
approved by the utilization review entity after appeal,

398
aggregated by item or service.

399
5.

The percentage of prior authorizations when the

400
timeframe for review was extended and request approved, by item

401
or service.

402
6.

The percentage of expedited prior authorization requests

403
approved by the utilization review entity, by item or service.

404
7.

The percentage of expedited prior authorization requests

405
denied by the utilization review entity, by item or service.

406
8.

The percentage of expedited prior authorization requests

407
approved by the utilization review entity after appeal, by item

408
or service.

409
9.

The average and median time between submission of a

410
request for prior authorization and the utilization review

411
entity’s decision for standard prior authorizations, by item or

412
service.

413
10.

The average and median time between submission of a

414
request for prior authorization and the utilization review

415
entity’s decision for expedited prior authorizations, by item or

416
service.

417
(b)

The Office of Insurance Regulation shall, by July 1 of

418
each year, publish a report on its website detailing the

419
information in paragraph (a) submitted by utilization review

420
entities.

421
(10)

Utilization review entities shall ensure that all

422
adverse determinations are made by a physician licensed under

423
chapter 458 or chapter 459. The physician:

424
(a)

Must possess a current and valid nonrestricted license

425
to practice medicine in this state;

426
(b)

Must be of the same specialty as the physician who

427
typically manages the medical condition or disease or provides

428
the health care service involved in the request;

429
(c)

Must have at least 5 years of experience treating

430
patients with the medical condition or disease for which the

431
health care service is being requested; and

432
(d)

May not have any direct or indirect financial

433
arrangement with the utilization review entity that rewards or

434
incentivizes, financially or otherwise, such physician in any

435
way relating to adverse determinations.

436
(11)

Notice of an adverse determination must be provided by

437
e-mail to the health care provider that initiated the prior

438
authorization and to the patient. Notice required under this

439
subsection must include:

440
(a)

The name, title, e-mail address, and telephone number

441
of the physician responsible for making the adverse

442
determination.

443
(b)

Any written clinical criteria and any internal rule,

444
guideline, or protocol on which the utilization review entity

445
relied when making the adverse determination and the reasons

446
those provisions apply to the patient’s specific medical

447
circumstance.

448
(c)

Information for the patient and the patient’s health

449
care provider which describes the procedure through which the

450
patient or health care provider may request a copy of any report

451
developed by personnel performing the review that led to the

452
adverse determination.

453
(d)

Information that explains to the patient and the

454
patient’s health care provider the manner in which to appeal the

455
adverse determination.

456
(12)

If a utilization review entity requires prior

457
authorization of a nonurgent health care service, the

458
utilization review entity must grant a prior authorization or

459
make an adverse determination and notify the patient and the

460
patient’s health care provider of the decision within 72 hours

461
after obtaining all necessary information to grant the prior

462
authorization or make the adverse determination. For purposes of

463
this subsection, the term “necessary information” includes the

464
results of any face-to-face clinical evaluation or second

465
opinion that may be required.

466
(13)

A utilization review entity shall grant an expedited

467
prior authorization or make an expedited adverse determination

468
concerning an urgent health care service and notify the patient

469
and the patient’s health care provider of such expedited prior

470
authorization or adverse determination no later than 24 hours

471
after receiving all information needed to complete the review of

472
the requested urgent health care service.

473
(14)(a)

A utilization review entity is prohibited from

474
requiring prior authorization for:

475
1.

Prehospital transportation;

476
2.

Provision of an emergency health care service; or

477
3.

Provision of a service to a patient who is experiencing

478
an emergency medical condition.

479
(b)

A utilization review entity is prohibited from

480
conducting utilization review activity, and from making any

481
adverse determinations, to the extent restricted or prohibited

482
by an agreement with a health care provider. A utilization

483
review entity is prohibited from performing any utilization

484
review activity, and from making any adverse determinations,

485
with respect to:

486
1.

An emergency health care service; or

487
2.

A service provided to a patient who experiences an

488
emergency medical condition.

489
(15)

A utilization review entity is prohibited from

490
requiring prior authorization, and from making any adverse

491
determinations, for the provision of medications for opioid use

492
disorder. For purposes of this subsection, the term “medications

493
for opioid use disorder” means the use of medications, commonly

494
prescribed in combination with counseling and behavioral

495
therapies, to provide a comprehensive approach to the treatment

496
of opioid use disorder. FDA-approved medications used to treat

497
opioid addiction include, but are not limited to, methadone,

498
buprenorphine, alone or in combination with naloxone, and

499
extended-release injectable naltrexone. Types of behavioral

500
therapies include, but are not limited to, individual therapy,

501
group counseling, family behavior therapy, motivational

502
incentives, and other modalities.

503
(16)

A utilization review entity is prohibited from

504
revoking, limiting, conditioning, or restricting a prior

505
authorization if care is provided within 45 business days after

506
the date the health care provider receives the prior

507
authorization. A utilization review entity must pay, or cause

508
payment to be made to, the health care provider, without any

509
prepayment review or prepayment audit before such payment, at

510
the contracted payment rate for a health care service provided

511
by the health care provider per the prior authorization, unless:

512
(a)

The health care provider knowingly and materially

513
misrepresented the health care service in the prior

514
authorization request with the specific intent to deceive and

515
obtain an unlawful payment from the utilization review entity;

516
(b)

The health care service was no longer a covered

517
benefit, and medical necessity did not constitute a basis for

518
such noncovered benefit status, on the day the health care

519
service was provided, and the utilization review entity notified

520
the health care provider in writing of these facts before the

521
health care service was provided;

522
(c)

The authorized service was never performed; or

523
(d)

The patient was no longer enrolled under the applicable

524
health plan and, on that basis, was not eligible for health care

525
coverage from the applicable health insurer or self-insured plan

526
on the day the care was provided, and the utilization review

527
entity notified the health care provider in writing of these

528
facts before the health care service was provided.

529
(17)

If a utilization review entity requires a prior

530
authorization for a health care service for the treatment of a

531
chronic or long-term care condition, the prior authorization

532
must remain valid for the length of the treatment, and the

533
utilization review entity is prohibited from requiring the

534
patient to obtain a prior authorization again for the health

535
care service.

536
(18)

A utilization review entity is prohibited from

537
imposing an additional prior authorization requirement with

538
respect to a surgical or otherwise invasive procedure, or any

539
item furnished as part of the surgical or invasive procedure, if

540
the procedure or item is furnished during the perioperative

541
period of another procedure for which prior authorization was

542
granted by the health insurer.

543
(19)

If there is a change in coverage or approval criteria

544
for a previously authorized health care service, the change in

545
coverage or approval criteria is prohibited from adversely

546
affecting an enrollee who received prior authorization before

547
the effective date of the change for the remainder of the

548
enrollee’s plan year.

549
(20)

A utilization review entity shall continue to honor a

550
prior authorization it has granted to an enrollee when the

551
enrollee changes products under the same health insurer.

552
(21)

Any failure by a utilization review entity to comply

553
with the deadlines and other requirements specified in this

554
section will result in any health care services subject to

555
review being automatically deemed authorized by the utilization

556
review entity.

557
(22)

Except as otherwise provided in paragraphs (16)(a)

558
(d), prior authorization constitutes a conclusive determination

559
of the medical necessity of the authorized health care service

560
and an irrevocable obligation to pay for such authorized health

561
care service.

562
(23)(a)

This section prohibits an agreement with a health

563
care provider to restrict, limit, prohibit, or substitute a

564
utilization review activity or prior authorization.

565
(b)

Nothing in this section may be construed to:

566
1.

Limit in any way the restrictions or prohibitions on

567
adverse determinations under an agreement with a health care

568
provider, nor to imply permission for, or applicability of,

569
adverse determinations for emergency health care services.

570
2.

Restrict, limit, or prohibit in any way prior

571
authorizations under an agreement between a provider and a

572
utilization review entity, nor to restrict, limit, or prohibit a

573
provider’s rights to contest, reject, or oppose any prior

574
authorization activities.

575
(24)

For a violation of this section, a provider shall have

576
a private cause of action to proceed against the health insurer

577
or utilization review entity in the applicable tribunal for the

578
violation.

579 Section 3. Section 627.6131, Florida Statutes, is amended
580 to read:
581 627.6131
Prompt
payment of claims.—
582 (1) The contract
must

shall
include the following
583 provision: “Time of Payment of Claims: After receiving written
584 proof of loss, the
health
insurer
shall

will
pay monthly all
585
claims. Claims

benefits then due for ...(type of benefit)....

586
Benefits
for any other loss covered by this policy
shall

will
be
587 paid as soon as the
health
insurer receives proper written
588 proof.”
589 (2) As used in this section, the term
:

590
(a)
“Claim” for a noninstitutional provider means a paper
591
HCFA 1500 claim form, or its successor,
or
an
electronic billing
592 instrument submitted to the
health
insurer’s designated location
593 that consists of the
ANSI ASC X12N 837P standard

HCFA 1500
data
594 set, or its successor, that has all mandatory entries for a
595 physician licensed under chapter 458, chapter 459, chapter 460,
596 chapter 461, or chapter 463, or psychologists licensed under
597 chapter 490 or any appropriate billing instrument
as designated

598
by the provider
that has all mandatory entries for any other
599 noninstitutional provider. For institutional providers, “claim”
600 means a paper
CMS-1450 claim form, or its successor,
or
an

601 electronic billing instrument submitted to the
health
insurer’s
602 designated location that consists of the
ANSI ASC X12N 837I

603
standard

UB-92 data
set
,
or its successor
,
with entries stated
604 as mandatory by the National Uniform Billing Committee.
605
(b)

“Clean claim” means a completed form, or completed

606
electronic billing instrument, containing all information

607
required under the applicable form or electronic billing

608
instrument, as well as information reasonably required by the

609
health insurer, other than for emergency services and care as

610
defined in s. 395.002, in advance of the provision of service by

611
the health insurer to substantiate the claim.

612
(c)

“Electronic medical record” means the digital record of

613
a patient’s information that may be accessed through electronic

614
means, via portal or other method of electronic access, which

615
may include information regarding the patient’s medical history,

616
medical condition, medical treatment, laboratory results,

617
diagnostic reports, and clinical notes.

618
(d)

“Emergency health care services” has the same meaning

619
as “emergency services and care” as defined in s. 395.002.

620
(e)

“Health insurer” means any entity that offers health

621
insurance coverage, whether through a fully insured plan or a

622
self-insured plan or fund, including, as applicable:

623
1.

An authorized health insurer offering health insurance

624
as defined in s. 624.603, as well as any entity that offers a

625
commercial self-insurance fund as defined in s. 624.462(2) or a

626
group self-insurance fund as described in s. 624.4621.

627
2.

A health insurer that is subject to any provision of

628
this chapter, as well as any entity that offers a self-insurance

629
plan or a group self-insurance plan.

630
(f)

“Insured ineligibility” means that the insured was no

631
longer enrolled in the health plan at the time of receiving the

632
applicable service.

633
(g)

“Overpayment” means payment made upon a claim that is:

634
1.

Billed in error;

635
2.

A duplicate claim; or

636
3.

Billed for a service rendered to a patient despite

637
insured ineligibility.

638
639
A request for overpayment is limited to a billing error,

640
duplicate bill, or insured ineligibility.

641 (3) All claims for payment or overpayment, whether
642 electronic or nonelectronic:
643 (a) Are considered received on the date the claim is
644 received by the
health
insurer at its designated claims-receipt
645 location or the date the
claim for
overpayment
claim
is received
646 by the provider at its designated location.
647 (b)
As to providers’ claims for payment,
must be mailed or
648 electronically transferred to the primary
health
insurer within
649 6 months after the following have occurred:
650 1. Discharge for inpatient services or the date of service
651 for outpatient services; and
652 2. The provider has been furnished with the correct name
653 and address of the patient’s health insurer.
654
655 All
providers’
claims for payment, whether electronic or
656 nonelectronic, must be mailed or electronically transferred to
657 the secondary
health
insurer within
45

90
days after final
658 determination by the primary
health
insurer. A provider’s claim
659 is considered submitted on the date it is electronically
660 transferred or mailed.
661 (c) Must not duplicate a claim previously submitted unless
662 it is determined that the original claim was not received or is
663 otherwise lost.
664 (4) For all electronically submitted claims, a health
665 insurer shall:
666 (a) Within 24 hours after the beginning of the next
667 business day after receipt of the claim, provide
to the

668
electronic source submitting the claim an
electronic
669 acknowledgment of the receipt of the claim
, accompanied by a

670
statement indicating the health insurer’s position as to whether

671
the claim is a clean claim or is missing any information that is

672
required under the applicable electronic billing instrument, as

673
described in paragraph (2)(a), or that was reasonably required

674
by the health insurer, other than for emergency health care

675
services, in advance of the provision of service to substantiate

676
to the electronic source submitting
the claim
, and the health

677
insurer asserts is missing as of the date of service
.
678 (b) Within
15

20
days after receipt of the claim, pay the
679 claim or notify a provider or designee if a claim is denied or
680 contested. Notice of the
health­
insurer’s action on the claim
681 and payment of the claim is considered to be made on the date
682 the notice or payment was
received by the provider

mailed
or
683 electronically transferred.
684 (c)1. Notification of the health insurer’s determination of
685 a contested claim must be accompanied by an itemized list of
any

686
additional
information
that is required under the applicable

687
billing instrument, as described in paragraph (2)(a), or that

688
was reasonably required by the health insurer, other than for

689
emergency health care services, in advance of the provision of

690
service to substantiate the claim, and the health insurer

691
asserts is missing as of the date of such service

or documents

692
the insurer can reasonably determine are necessary to process

693
the claim
.
694 2. A provider must submit the additional information or
695 documentation, as specified on the itemized list, within
30

35

696 days after receipt of the notification
of contestation unless,

697
within the 30-day period, the provider notifies the health

698
insurer of the provider’s position that a clean claim has been

699
submitted
. Additional information is considered submitted on the
700 date it is electronically transferred or mailed. The health
701 insurer
is prohibited from requesting

may not request
duplicate
702 documents.
703 (d) For purposes of this subsection, electronic means of
704 transmission of claims, notices, documents, forms, and payments
705 shall be used to the greatest extent possible by the health
706 insurer and the provider.
707 (e) A claim
contested by the health insurer
must be paid or
708 denied within
30

90
days after receipt of the
additional

709
information requested

claim
. Failure to pay or deny a claim
710 within
90

120
days after receipt of the claim
, regardless of

711
whether contested by the health insurer,
creates an
712 uncontestable obligation to pay the claim
as submitted by the

713
provider
.
714 (5) For all nonelectronically submitted claims, a health
715 insurer shall:
716 (a)
Within 15 days following receipt of the claim

Effective

717
November 1, 2003
, provide
to the provider or its designee:

718
1.

An
acknowledgment of receipt of the claim
, accompanied

719
by a statement indicating the health insurer’s position as to

720
whether the claim is a clean claim or the claim is missing any

721
information that is required under the applicable paper billing

722
form, as described in paragraph (2)(a), or that was reasonably

723
required by the health insurer, other than for emergency health

724
care services, in advance of the provision of service to

725
substantiate the claim, and the health insurer asserts is

726
missing as of the date of service; or

727
2.

within 15 days after receipt of the claim to the

728
provider or provide a provider within 15 days after receipt with

729 Electronic access to the status of
the

a
submitted claim
, which

730
status must indicate the health insurer’s position as to whether

731
the claim is a clean claim or missing any information described

732
in subparagraph 1
.
733 (b) Within
30

40
days after receipt of the claim, pay the
734 claim or notify a provider or designee if a claim is denied or
735 contested. Notice of the
health
insurer’s action on the claim
736 and payment of the claim is considered to be made on the date
737 the notice or payment was
received by the provider

mailed
or
738 electronically transferred.
739 (c)1. Notification of the health insurer’s determination of
740 a contested claim must be accompanied by an itemized list of
any

741
additional
information
that is required under the applicable

742
form or billing instrument, as described in paragraph (2)(a), or

743
that was reasonably required by the health insurer, other than

744
for emergency health care services, in advance of the provision

745
of service to substantiate the claim, and the health insurer

746
asserts is missing as of the date of such service

or documents

747
the insurer can reasonably determine are necessary to process

748
the claim
.
749 2. A provider must submit the additional information or
750 documentation, as specified on the itemized list, within
30

35

751 days after receipt of the notification
of contestation unless,

752
within the 30-day period, the provider notifies the health

753
insurer of its position that a clean claim has been submitted
.
754 Additional information is considered submitted on the date it is
755 electronically transferred or mailed. The health insurer
is

756
prohibited from requesting

may not request
duplicate documents.
757 (d) For purposes of this subsection, electronic means of
758 transmission of claims, notices, documents, forms, and payments
759
must

shall
be used to the greatest extent possible by the health
760 insurer and the provider.
761 (e) A claim
contested by the health insurer
must be paid or
762 denied within
30

120
days after receipt of the
additional

763
information requested

claim
. Failure to pay or deny a claim
764 within
90

140
days after receipt of the claim
, regardless of

765
whether contested by the health insurer,
creates an
766 uncontestable obligation to pay the claim
as submitted by the

767
provider
.
768
(6)

Regardless of whether a claim has been submitted

769
electronically or nonelectronically, and notwithstanding any

770
other provision of this section:

771
(a)

Once a provider grants a health insurer access to a

772
patient’s electronic medical record, the provider is deemed to

773
have supplied all information necessary to pay the claim,

774
including, without limitation, all information that is required

775
under the applicable billing instrument and that was reasonably

776
required by the health insurer, other than for emergency health

777
care services, in advance of the provision of service to

778
substantiate the claim. Additional information or documentation,

779
regardless of whether the health insurer requests any additional

780
information, is deemed unnecessary, and deemed not required for

781
payment of the claim, and any request for additional

782
information, and any position of the health insurer or any third

783
party acting on behalf of the health insurer regarding any lack

784
of information from the provider, is prohibited from being used

785
to deny, reduce, offset, withhold, pend, or delay payment of the

786
claim.

787
(b)

If notice of access to the electronic medical record

788
has been provided to the health insurer, the claim must be paid

789
or denied within 30 days of such notice to the health insurer.

790
Failure to pay or deny a claim for which the health insurer has

791
been provided notice of access to the electronic medical record

792
within 75 days after receipt of such notice creates an

793
uncontestable obligation to pay the claim as submitted by the

794
provider.

795
(7)
(6)
If a health insurer determines that it has made an
796 overpayment to a provider for services rendered to an insured,
797 the health insurer must make
an overpayment

a
claim for such
798 overpayment to the provider’s designated location. A health
799 insurer that makes
an overpayment

a
claim
for overpayment
to a
800 provider under this section shall give the provider a written or
801 electronic statement specifying the basis for the
retrospective

802
retroactive
denial or payment adjustment. The
health
insurer
803 must
also
identify the claim or claims, or
portion thereof, as

804
to which the health insurer alleges
overpayment
claim
, and the

805
specific invoice number submitted with or on the claim

portion

806
thereof, for which a claim for overpayment is submitted
.
Except

807
as provided in subparagraph (a)3., there may be no denial,

808
reduction, offset, withholding, pending, or delay of payment, or

809
other negative impact, regardless of whether by the health

810
insurer or any third party acting on behalf of such health

811
insurer, on payment of any other claim of the provider on the

812
basis of the overpayment allegation.

813 (a) If an overpayment determination is the result of
814
retrospective

retroactive
review or
retrospective
audit
of

815
coverage decisions or payment levels not related to fraud
, a
816 health insurer
must

shall
adhere to the following procedures:
817 1. All
overpayment
claims
for overpayment
must be
received

818
by the

submitted to a
provider within
18

30
months after the
819 health insurer’s payment of the claim. A provider must pay,
820 deny, or contest the health insurer’s
claim for
overpayment
821
claim
within 40 days after the receipt of the
overpayment
claim.
822 All contested
overpayment
claims
for overpayment
must be paid or
823 denied within 120 days after receipt of the
overpayment
claim.
824 Failure to pay or deny
an
overpayment
and
claim within 140 days
825 after receipt creates an uncontestable obligation to pay the
826
overpayment
claim.
827 2. A provider that denies or contests a health insurer’s
828
overpayment
claim
for overpayment
or any portion of
an

829
overpayment

a
claim shall notify the health insurer, in writing,
830 within
40

35
days after the provider receives the
overpayment

831 claim that
such overpayment

the
claim
for overpayment
is
832 contested or denied. The notice that the
overpayment
claim
for

833
overpayment
is denied or contested must identify the
denied or

834 contested portion of the
overpayment
claim and the specific
835 reason for contesting or denying the
overpayment
claim and, if
836 contested, must include a request for additional information. If
837 the health insurer submits additional information, the health
838 insurer must, within 35 days after receipt of the request, mail
839 or electronically transfer the information to the provider. The
840 provider shall pay or deny the
overpayment
claim
for overpayment

841 within 45 days after receipt of the information. The notice
from

842
the provider regarding denial or contestation of the overpayment

843
claim
is considered made on the date the notice is mailed or
844 electronically transferred by the provider.
845 3. The health insurer
is prohibited from denying, reducing,

846
offsetting, withholding, pending, or delaying

may not reduce

847 payment to the provider for other services unless the provider
848 agrees to the
denial,
reduction
, offset, withholding, pending,

849
or delay of payment
in writing or fails to respond to the health
850 insurer’s overpayment claim as required by this paragraph.
851 4. Payment of an overpayment claim is considered made on
852 the date the payment was mailed or electronically transferred.
853 An overdue payment of a claim bears simple interest at the rate
854 of 12 percent per year. Interest on an overdue payment for
an

855
overpayment

a
claim
for an overpayment
begins to accrue when the
856
overpayment
claim should have been paid
, denied, or contested
.
857 (b)
An overpayment

A
claim
is prohibited

for overpayment

858
shall not be permitted
beyond
18

30
months after the health
859 insurer’s payment of a claim, except that
overpayment
claims
for

860
overpayment
may be sought beyond that time from providers
861 convicted of fraud pursuant to s. 817.234.
862
(8)
(7)
Payment of a claim is considered made on the date
863 the payment was mailed or electronically transferred. An overdue
864 payment of a claim bears simple interest of
15

12
percent per
865 year
, to be calculated on the full total amount that should have

866
been paid on the claim within the applicable time period

867
specified in this section. If an applicable court, arbitration

868
tribunal, or other binding legal process determines that a claim

869
that was paid at a lesser amount should have been paid at a full

870
total amount, whether under a breach of contract legal claim, a

871
legal claim under a statutory private cause of action, or other

872
basis, the 15 percent per year interest must be calculated on

873
the full total amount, rather than upon the difference between

874
the full total amount and the amount that was actually paid. If

875
an applicable court, arbitration tribunal, or other binding

876
legal process determines that a claim was subject to an

877
inappropriate or impermissible denial or partial denial, whether

878
in a breach of contract, statute, common law, or otherwise,

879
interest must be calculated on the full total amount that should

880
have been paid on the claim within the applicable time period

881
for payment specified in this section, and the act of denial or

882
partial denial is deemed not to have in any way tolled the time

883
period for such payment
. Interest on
the full total amount that

884
should have been paid on the claim within the applicable time

885
period specified in this section

an overdue payment for a claim

886
or for any portion of a claim
begins to accrue when the claim
887 should have been paid
, denied, or contested
. The interest
must

888
be paid along with, and in addition to, the payment for the

889
satisfaction of the full total amount of the claim, as

890
determined by an applicable court, arbitration tribunal, or

891
other binding legal process

is payable with the payment of the

892
claim
.
893
(9)
(8)
For all contracts entered into or renewed on or
894 after October 1, 2002, a health insurer’s internal dispute
895 resolution process related to a denied claim not under active
896 review by a mediator, arbitrator, or third-party dispute entity
897 must be finalized within 60 days after the receipt of the
898 provider’s request for review or appeal.
Notwithstanding any

899
provision of this section, when the provider and health insurer

900
disagree as to interpretation of contractual or statutory

901
language, the provider is not required to participate in the

902
health insurer’s internal dispute resolution process.

903
(10)
(9)
A provider or any representative of a provider,
904 regardless of whether the provider is under contract with the
905 health insurer,
is prohibited from collecting or attempting

may

906
not collect or attempt
to collect money from,
maintaining

907
maintain
any action at law against, or
reporting

report
to a
908 credit agency an insured for payment of covered services for
909 which the health insurer contested or denied the provider’s
910 claim. This prohibition applies during the pendency of any claim
911 for payment made by the provider to the health insurer for
912 payment of the services or internal dispute resolution process
913 to determine whether the health insurer is liable for the
914 services. For a claim, this pendency applies from the date the
915 claim or a portion of the claim is denied to the date of the
916 completion of the health insurer’s internal dispute resolution
917 process, not to exceed 60 days. This subsection does not
918 prohibit the collection by the provider of copayments,
919 coinsurance, or deductible amounts due the provider.
920
(10)

The provisions of this section may not be waived,

921
voided, or nullified by contract.

922 (11) A health insurer
is prohibited from retrospectively

923
denying

may not retroactively deny
a claim because of insured
924 ineligibility more than
90 days

1 year
after the date of payment
925 of the claim.
926 (12) A health insurer
must

shall
pay a contracted primary
927 care or admitting physician, pursuant to such physician’s
928 contract, for providing inpatient services in a contracted
929 hospital to an insured if such services are determined by
such

930
physician

the health insurer
to be medically necessary and
,

931
regardless of the health plan’s determination of medical

932
necessity, are otherwise
covered services under the health
933 insurer’s contract with the contract holder.
934 (13) Upon written notification by an insured,
a health

an

935 insurer shall investigate any claim of improper billing
of the

936
insured
by a physician, hospital, or other health care provider
937
for a health care service alleged to not actually have been

938
received
. The
health
insurer shall determine
whether

if
the
939 insured
actually received the applicable service

was properly

940
billed for only those procedures and services that the insured

941
actually received
. If the
health
insurer determines that the
942 insured
did not actually receive the applicable service

has been

943
improperly billed
, the
health
insurer
must

shall
notify the
944 insured and the provider of its findings and
must

shall
reduce
945 the amount of payment to the provider by the amount
for the

946
service that was not actually received

determined to be

947
improperly billed
.
If a reduction is made due to such

948
notification by the insured, the insurer shall pay to the

949
insured 20 percent of the amount of the reduction up to $500
.
950 (14) A permissible error ratio of 5 percent is established
951 for
health
insurer’s claims payment violations of paragraphs
952 (4)(a), (b), (c), and (e) and (5)(a), (b), (c), and (e). If the
953 error ratio of a particular
health
insurer does not exceed the
954 permissible error ratio of 5 percent for an audit period, no
955 fine
may

shall
be assessed for the noted claims violations for
956 the audit period. The error ratio
is

shall be
determined by
957 dividing the number of claims with violations found on a
958 statistically valid sample of claims for the audit period by the
959 total number of claims in the sample. If the error ratio exceeds
960 the permissible error ratio of 5 percent, a fine may be assessed
961 according to s. 624.4211 for those claims payment violations
962 which exceed the error ratio. Notwithstanding the provisions of
963 this section, the office may fine a health insurer for claims
964 payment violations of paragraphs (4)(e) and (5)(e) which create
965 an uncontestable obligation to pay the claim
as submitted by the

966
provider
. The office shall
refrain from imposing a

not
fine
upon

967
a health insurer

insurers
for violations which the office
968 determines were due to circumstances beyond the
health
insurer’s
969 control.
970 (15) This section is applicable only to a major medical
971 expense health insurance policy as defined in s. 627.643(2)(e)
972 offered by a group or an individual health insurer licensed
973
under

pursuant to
chapter 624, including a preferred provider
974 policy under s. 627.6471 and an exclusive provider organization
975 under s. 627.6472 or a group or individual insurance contract
976 that only provides direct payments to dentists for enumerated
977 dental services
, or other health insurance coverage, policy, or

978
fund, regardless of whether fully insured or self-insured,

979
offered or administered by a health insurer
.
980 (16) Notwithstanding paragraph (4)(b), where an electronic
981 pharmacy claim is submitted to a pharmacy benefits manager
982 acting on behalf of a health insurer, the pharmacy benefits
983 manager shall, within 30 days of receipt of the claim, pay the
984 claim or notify a provider or designee if a claim is denied or
985 contested. Notice of the
health
insurer’s action on the claim
986 and payment of the claim is considered to be made on the date
987 the notice or payment was
received by the provider

mailed
or
988 electronically transferred.
989 (17) Notwithstanding paragraph (5)(a), effective November
990 1, 2003, where a nonelectronic pharmacy claim is submitted to a
991 pharmacy benefits manager acting on behalf of a health insurer,
992 the pharmacy benefits manager shall provide acknowledgment of
993 receipt of the claim within 30 days after receipt of the claim
994 to the provider or provide a provider within 30 days after
995 receipt with electronic access to the status of a submitted
996 claim.
997 (18) Notwithstanding the
18-month

30-month
period provided
998 in subsection
(7)

(6)
, all
overpayment
claims
for overpayment

999 submitted to a provider licensed under
chapter 395,
chapter 458,
1000 chapter 459, chapter 460, chapter 461,
chapter 463,
chapter 466,
1001 or chapter 490 must be submitted to the provider within 12
1002 months after the health insurer’s payment of the claim.
An

1003
overpayment

A
claim
to a provider licensed under chapter 395,

1004
chapter 458, chapter 459, chapter 460, chapter 461, chapter 463,

1005
chapter 466, or chapter 490 is prohibited

for overpayment may

1006
not be permitted
beyond 12 months after the health insurer’s
1007 payment of a claim, except that
overpayment
claims
for

1008
overpayment
may be sought beyond that time from providers
1009 convicted of fraud pursuant to s. 817.234.
1010 (19) Notwithstanding any other provision of this section,
1011 all claims for underpayment from a provider licensed under
1012
chapter 395,
chapter 458, chapter 459, chapter 460, chapter 461,
1013 or chapter 466 must be submitted to the
health
insurer within 12
1014 months after the health insurer’s payment of the claim. A claim
1015 for underpayment
by a provider licensed under chapter 395,

1016
chapter 458, chapter 459, chapter 460, chapter 461, or chapter

1017
466 is prohibited

may not be permitted
beyond 12 months after
1018 the health insurer’s payment of a claim.
1019
(20)

Nothing in this section shall be interpreted to limit,

1020
restrict, or negatively impact any legal claim by a provider or

1021
health insurer for breach of contract, statutory or regulatory

1022
violation, or a common-law cause of action, nor to shorten or

1023
otherwise negatively impact the statute of limitations timeframe

1024
for bringing any such legal claim.

1025
(21)

A health insurer is prohibited from requesting

1026
information from a contracted or noncontracted provider which

1027
does not apply to the medical condition at issue for the

1028
purposes of adjudicating a clean claim.

1029
(22)

A health insurer is prohibited from requesting a

1030
contracted or noncontracted provider to resubmit claim

1031
information that the contracted or noncontracted provider can

1032
document it has already provided to the health insurer or that

1033
is contained inside the electronic medical record to which the

1034
health insurer has been provided access.

1035
(23)

Notwithstanding any other provision of this section, a

1036
health insurer is prohibited from requiring any information from

1037
a provider before the provision of emergency health care

1038
services as a condition of payment of a claim, as a basis for

1039
denying, delaying, offsetting, withholding, or reducing payment

1040
of a claim, or in contesting whether the claim is a clean claim.

1041
(24)

For a violation of this section, a provider shall have

1042
a private cause of action to proceed against the health insurer

1043
in the applicable tribunal for the violation.

1044
(25)
(20)
(a) A contract between a health insurer and a
1045 dentist licensed under chapter 466 for the provision of services
1046 to an insured
is prohibited from specifying

may not specify

1047 credit card payment as the only acceptable method for payments
1048 from the health insurer to the dentist.
1049 (b) When a health insurer employs the method of claims
1050 payment to a dentist through electronic funds transfer,
1051 including, but not limited to, virtual credit card payment, the
1052 health insurer shall notify the dentist as provided in this
1053 paragraph and obtain the dentist’s consent before employing the
1054 electronic funds transfer. The dentist’s consent described in
1055 this paragraph applies to the dentist’s entire practice. For the
1056 purpose of this paragraph, the dentist’s consent, which may be
1057 given through e-mail, must bear the signature of the dentist.
1058 Such signature includes an electronic or digital signature if
1059 the form of signature is recognized as a valid signature under
1060 applicable federal law or state contract law or an act that
1061 demonstrates express consent, including, but not limited to,
1062 checking a box indicating consent. The
health
insurer or dentist
1063
is prohibited from requiring

may not require
that a dentist’s
1064 consent as described in this paragraph be made on a patient-by
1065 patient basis. The notification provided by the health insurer
1066 to the dentist must include all of the following:
1067 1. The fees, if any, associated with the electronic funds
1068 transfer.
1069 2. The available methods of payment of claims by the health
1070 insurer, with clear instructions to the dentist on how to select
1071 an alternative payment method.
1072 (c) A health insurer that pays a claim to a dentist through
1073 automated clearinghouse transfer
is prohibited from charging

may

1074
not charge
a fee solely to transmit the payment to the dentist
1075 unless the dentist has consented to the fee.
1076 (d) This subsection applies to contracts delivered, issued,
1077 or renewed on or after January 1, 2025.
1078 (e) The office has all rights and powers to enforce this
1079 subsection as provided by s. 624.307.
1080 (f) The commission may adopt rules to implement this
1081 subsection.
1082
(26)
(21)
(a) A health insurer
is prohibited from denying

may

1083
not deny
any claim subsequently submitted by a dentist licensed
1084 under chapter 466 for procedures specifically included in a
1085 prior authorization unless at least one of the following
1086 circumstances applies for each procedure denied:
1087 1. Benefit limitations, such as annual maximums and
1088 frequency limitations not applicable at the time of the prior
1089 authorization, are reached subsequent to issuance of the prior
1090 authorization.
1091 2. The documentation provided by the person submitting the
1092 claim fails to support the claim as originally authorized.
1093 3. Subsequent to the issuance of the prior authorization,
1094 new procedures are provided to the patient or a change in the
1095 condition of the patient occurs such that the prior authorized
1096 procedure would no longer be considered medically necessary,
1097 based on the prevailing standard of care.
1098 4. Subsequent to the issuance of the prior authorization,
1099 new procedures are provided to the patient or a change in the
1100 patient’s condition occurs such that the prior authorized
1101 procedure would at that time have required disapproval pursuant
1102 to the terms and conditions for coverage under the patient’s
1103 plan in effect at the time the prior authorization was issued.
1104 5. The denial of the claim was due to one of the following:
1105 a. Another payor is responsible for payment.
1106 b. The dentist has already been paid for the procedures
1107 identified in the claim.
1108 c. The claim was submitted fraudulently, or the prior
1109 authorization was based in whole or material part on erroneous
1110 information provided to the health insurer by the dentist,
1111 patient, or other person not related to the
health
insurer.
1112 d. The person receiving the procedure was not eligible to
1113 receive the procedure on the date of service.
1114 e. The services were provided during the grace period
1115 established under s. 627.608 or applicable federal regulations,
1116 and the dental insurer notified the provider that the patient
1117 was in the grace period when the provider requested eligibility
1118 or enrollment verification from the dental insurer, if such
1119 request was made.
1120 (b) This subsection applies to all contracts delivered,
1121 issued, or renewed on or after January 1, 2025.
1122 (c) The office has all rights and powers to enforce this
1123 subsection as provided by s. 624.307.
1124 (d) The commission may adopt rules to implement this
1125 subsection.
1126 Section 4. Section 641.3155, Florida Statutes, is amended
1127 to read:
1128 641.3155 Prompt payment of claims.—
1129 (1) As used in this section, the term
:

1130
(a)
“Claim” for a noninstitutional provider means a paper
1131
HCFA 1500 claim form, or its successor,
or
an
electronic billing
1132 instrument submitted to the health maintenance organization’s
1133 designated location that consists of the
ANSI ASC X12N 837P

1134
standard

HCFA 1500
data set, or its successor, that has all
1135 mandatory entries for a physician licensed under chapter 458,
1136 chapter 459, chapter 460, chapter 461, or chapter 463, or
1137 psychologists licensed under chapter 490 or any appropriate
1138 billing instrument
as designated by the provider
that has all
1139 mandatory entries for any other noninstitutional provider. For
1140 institutional providers, “claim” means a paper
CMS-1450 claim

1141
form, or its successor,
or
an
electronic billing instrument
1142 submitted to the health maintenance organization’s designated
1143 location that consists of the
ANSI ASC X12N 837I standard

UB-92

1144 data set or its successor with entries stated as mandatory by
1145 the National Uniform Billing Committee.
1146
(b)

“Clean claim” means a completed form, or completed

1147
electronic billing instrument, containing all information

1148
required under the applicable form or electronic billing

1149
instrument, as well as information reasonably required by the

1150
health maintenance organization, other than for emergency

1151
services and care as defined in s. 641.19, in advance of the

1152
provision of service by the health maintenance organization to

1153
substantiate the claim.

1154
(c)

“Electronic medical record” means the digital record of

1155
a patient’s information that may be accessed through electronic

1156
means, via portal or other method of electronic access, which

1157
may include information regarding the patient’s medical history,

1158
medical condition, medical treatment, laboratory results,

1159
diagnostic reports, and clinical notes.

1160
(d)

“Emergency health care service” has the same meaning as

1161
“emergency services and care” as defined in s. 641.19.

1162
(e)

“Enrollee ineligibility” means that the enrollee was no

1163
longer enrolled in the health maintenance organization at the

1164
time of receiving the applicable service.

1165
(f)

“Overpayment” means payment made upon a claim that is:

1166
1.

Billed in error;

1167
2.

A duplicate claim; or

1168
3.

Billed for a service rendered to a patient despite

1169
enrollee ineligibility.

1170
1171
A request for overpayment is limited to a billing error,

1172
duplicate bill, or enrollee ineligibility.

1173 (2) All claims for payment or overpayment, whether
1174 electronic or nonelectronic:
1175 (a) Are considered received on the date the claim is
1176 received by the
health maintenance
organization at its
1177 designated claims-receipt location or the date
the overpayment

a

1178 claim
for overpayment
is received by the provider at its
1179 designated location.
1180 (b)
As to providers’ claims for payment,
must be mailed or
1181 electronically transferred to the primary organization within 6
1182 months after the following have occurred:
1183 1. Discharge for inpatient services or the date of service
1184 for outpatient services; and
1185 2. The provider has been furnished with the correct name
1186 and address of the patient’s health maintenance organization.
1187
1188 All
providers’
claims for payment, whether electronic or
1189 nonelectronic, must be mailed or electronically transferred to
1190 the secondary organization within
45

90
days after final
1191 determination by the primary organization. A provider’s claim is
1192 considered submitted on the date it is electronically
1193 transferred or mailed.
1194 (c) Must not duplicate a claim previously submitted unless
1195 it is determined that the original claim was not received or is
1196 otherwise lost.
1197 (3) For all electronically submitted claims, a health
1198 maintenance organization shall:
1199 (a) Within 24 hours after the beginning of the next
1200 business day after receipt of the claim, provide
to the

1201
electronic source submitting the claim an
electronic
1202 acknowledgment of the receipt of the claim
, accompanied by a

1203
statement indicating the health maintenance organization’s

1204
position as to whether the claim is a clean claim or whether the

1205
claim is missing any information that is required under the

1206
applicable electronic billing instrument described in paragraph

1207
(1)(a) or that was reasonably required by the health maintenance

1208
organization, other than for emergency health care services, in

1209
advance of the provision of service to substantiate

to the

1210
electronic source submitting
the claim
, and the health

1211
maintenance organization asserts is missing as of the date of

1212
service
.
1213 (b) Within
15

20
days after receipt of the claim, pay the
1214 claim or notify a provider or designee if a claim is denied or
1215 contested. Notice of the
health maintenance
organization’s
1216 action on the claim and payment of the claim is considered to be
1217 made on the date the notice or payment was
received by the

1218
provider

mailed
or electronically transferred.
1219 (c)1. Notification of the health maintenance organization’s
1220 determination of a contested claim must be accompanied by an
1221 itemized list of
any

additional
information
required under the

1222
applicable billing instrument described in paragraph (1)(a) or

1223
that was reasonably required by the health maintenance

1224
organization, other than for emergency health care services, in

1225
advance of the provision of service to substantiate the claim,

1226
and the health maintenance organization asserts is missing as of

1227
the date of such service

or documents the insurer can reasonably

1228
determine are necessary to process the claim
.
1229 2. A provider must submit the additional information or
1230 documentation, as specified on the itemized list, within
30

35

1231 days after receipt of the notification
of contestation unless,

1232
within the 30-day period, the provider notifies the health

1233
maintenance organization of the provider’s position that a clean

1234
claim has been submitted
. Additional information is considered
1235 submitted on the date it is electronically transferred or
1236 mailed. The health maintenance organization
is prohibited from

1237
requesting

may not request
duplicate documents.
1238 (d) For purposes of this subsection, electronic means of
1239 transmission of claims, notices, documents, forms, and payment
1240 shall be used to the greatest extent possible by the health
1241 maintenance organization and the provider.
1242 (e) A claim
contested by the health maintenance

1243
organization
must be paid or denied within
30

90
days after
1244 receipt of the
additional information requested

claim
. Failure
1245 to pay or deny a claim within
90

120
days after receipt of the
1246 claim
, regardless of whether contested by the health maintenance

1247
organization,
creates an uncontestable obligation to pay the
1248 claim.
1249 (4) For all nonelectronically submitted claims, a health
1250 maintenance organization shall:
1251 (a)
Within 15 days following receipt of the claim

Effective

1252
November 1, 2003
, provide
to the provider, or designee, who

1253
submitted the claim:

1254
1.

An
acknowledgment of receipt of the claim
, accompanied

1255
by a statement indicating the health maintenance organization’s

1256
position as to whether the claim is a clean claim or the claim

1257
is missing any information that is required under the applicable

1258
paper billing form, as described in paragraph (1)(a), or that

1259
was reasonably required by the health maintenance organization,

1260
other than for emergency health care services, in advance of the

1261
provision of service to substantiate the claim, and the health

1262
maintenance organization asserts is missing as of the date of

1263
service; or

1264
2.

within 15 days after receipt of the claim to the

1265
provider or designee or provide a provider or designee within 15

1266
days after receipt with
Electronic access to the status of
the

a

1267 submitted claim
, which status must indicate the health

1268
maintenance organization’s position as to whether the claim is a

1269
clean claim or missing any information described in subparagraph

1270
1
.
1271 (b) Within
30

40
days after receipt of the claim, pay the
1272 claim or notify a provider or designee if a claim is denied or
1273 contested. Notice of the health maintenance organization’s
1274 action on the claim and payment of the claim is considered to be
1275 made on the date the notice or payment was
received by the

1276
provider

mailed
or electronically transferred.
1277 (c)1. Notification of the health maintenance organization’s
1278 determination of a contested claim must be accompanied by an
1279 itemized list of
any

additional
information
required under the

1280
applicable form or billing instrument described in paragraph

1281
(1)(a), or that was reasonably required by the health

1282
maintenance organization, other than for emergency health care

1283
services, in advance of the provision of service to substantiate

1284
the claim, and the health maintenance organization asserts is

1285
missing as of the date of such service

or documents the

1286
organization can reasonably determine are necessary to process

1287
the claim
.
1288 2. A provider must submit the additional information or
1289 documentation, as specified on the itemized list, within
30

35

1290 days after receipt of the notification
of contestation unless,

1291
within the 30-day period, the provider notifies the health

1292
maintenance organization of the provider’s position that a clean

1293
claim has been submitted
. Additional information is considered
1294 submitted on the date it is electronically transferred or
1295 mailed. The health maintenance organization
is prohibited from

1296
requesting

may not request
duplicate documents.
1297 (d) For purposes of this subsection, electronic means of
1298 transmission of claims, notices, documents, forms, and payments
1299
must

shall
be used to the greatest extent possible by the health
1300 maintenance organization and the provider.
1301 (e) A claim
contested by the health maintenance

1302
organization
must be paid or denied within
30

120
days after
1303 receipt of the
additional information requested

claim
. Failure
1304 to pay or deny a claim within
90

140
days after receipt of the
1305 claim
, regardless of whether contested by the health maintenance

1306
organization,
creates an uncontestable obligation to pay the
1307 claim
as submitted by the provider
.
1308
(5)

Regardless of whether a claim has been submitted

1309
electronically or nonelectronically, and notwithstanding any

1310
other provision of this section:

1311
(a)

Once a provider grants a health maintenance

1312
organization access to a patient’s electronic medical record,

1313
the provider is deemed to have supplied all information

1314
necessary to pay the claim, including, without limitation, all

1315
information that is required under the applicable billing

1316
instrument and that was reasonably required by the health

1317
maintenance organization, other than for emergency health care

1318
services, in advance of the provision of service to substantiate

1319
the claim. Additional information or documentation, regardless

1320
of whether the health maintenance organization requests any

1321
additional information, is deemed unnecessary and deemed not

1322
required for payment of the claim, and any request for

1323
additional information, and any position of the health

1324
maintenance organization or any third party acting on behalf of

1325
the health maintenance organization regarding any lack of

1326
information from the provider, is prohibited from being used to

1327
deny, reduce, offset, withhold, pend, or delay payment of the

1328
claim.

1329
(b)

If notice of access to the electronic medical record

1330
has been provided to the health maintenance organization, the

1331
claim must be paid or denied within 30 days of such notice to

1332
the health maintenance organization. Failure to pay or deny a

1333
claim, for which the health maintenance organization has been

1334
provided notice of access to the electronic medical record

1335
within 75 days after receipt of such notice, creates an

1336
uncontestable obligation to pay the claim as submitted by the

1337
provider.

1338
(6)
(5)
If a health maintenance organization determines that
1339 it has made an overpayment to a provider for services rendered
1340 to
an enrollee

a subscriber
, the health maintenance organization
1341 must make
an overpayment

a
claim for such overpayment to the
1342 provider’s designated location. A health maintenance
1343 organization that makes
an overpayment

a
claim
for overpaymen
t
1344 to a provider under this section shall give the provider a
1345 written or electronic statement specifying the basis for the
1346
retrospective

retroactive
denial or payment adjustment. The
1347 health maintenance organization must
also
identify the claim or
1348 claims, or
overpayment claim
portion thereof,
as to which the

1349
health maintenance organization alleges overpayment, and the

1350
specific invoice number submitted with or on the claim, as well

1351
as the specific line items on the bill that are subject to the

1352
overpayment claim

for which a claim for overpayment is

1353
submitted
.
Except as provided in subparagraph (a)3., there may

1354
be no denial, reduction, offset, withholding, pending, or delay

1355
of payment, or other negative impact, regardless of whether by

1356
the health maintenance organization or any third party acting on

1357
behalf of such health maintenance organization, on payment of

1358
any other claim of the provider on the basis of the overpayment

1359
allegation.

1360 (a) If an overpayment determination is the result of
1361
retrospective

retroactive
review or
retrospective
audit
of

1362
coverage decisions or payment levels not related to fraud
, a
1363 health maintenance organization
must

shall
adhere to the
1364 following procedures:
1365 1. All
overpayment
claims
for overpayment
must be
received

1366
by the

submitted to a
provider within
18

30
months after the
1367 health maintenance organization’s payment of the claim. A
1368 provider must pay, deny, or contest the health maintenance
1369 organization’s
overpayment
claim
for overpayment
within 40 days
1370 after the receipt of the
overpayment
claim. All contested
1371
overpayment
claims
for overpayment
must be paid or denied within
1372 120 days after receipt of the
overpayment
claim. Failure to pay
1373 or deny
an
overpayment
and
claim within 140 days after receipt
1374 creates an uncontestable obligation to pay the
overpayment

1375 claim.
1376 2. A provider that denies or contests a health maintenance
1377 organization’s
overpayment
claim
for overpayment
or any portion
1378 of
an overpayment

a
claim shall notify the
health maintenance

1379 organization, in writing, within
40

35
days after the provider
1380 receives the
overpayment
claim that the
overpayment
claim
for

1381
overpayment
is contested or denied. The notice that the
1382
overpayment
claim
for overpayment
is denied or contested must
1383 identify the
denied or
contested portion of the claim and the
1384 specific reason for contesting or denying the
overpayment
claim
1385 and, if contested, must include a request for additional
1386 information. If the
health maintenance
organization submits
1387 additional information, the
health maintenance
organization
1388 must, within 35 days after receipt of the request, mail or
1389 electronically transfer the information to the provider. The
1390 provider shall pay or deny the
overpayment
claim
for overpayment

1391 within 45 days after receipt of the information. The notice
from

1392
the provider regarding denial or contestation of the overpayment

1393
claim
is considered made on the date the notice is mailed or
1394 electronically transferred by the provider.
1395 3. The health maintenance organization
is prohibited from

1396
denying, reducing, offsetting, withholding, pending, or delaying

1397
may not reduce
payment to the provider for other services unless
1398 the provider agrees to the
denial,
reduction
, offset,

1399
withholding, pending, or delay of payment
in writing or fails to
1400 respond to the health maintenance organization’s overpayment
1401 claim as required by this paragraph.
1402 4. Payment of an overpayment claim is considered made on
1403 the date the payment was mailed or electronically transferred.
1404 An overdue payment of a claim bears simple interest at the rate
1405 of 12 percent per year. Interest on an overdue payment for
an

1406
overpayment

a
claim
for an overpayment payment
begins to accrue
1407 when the
overpayment
claim should have been paid
, denied, or

1408
contested
.
1409 (b)
An overpayment

A
claim
is prohibited

for overpayment

1410
shall not be permitted
beyond
18

30
months after the health
1411 maintenance organization’s payment of a claim, except that
1412
overpayment
claims
for overpayment
may be sought beyond that
1413 time from providers convicted of fraud pursuant to s. 817.234.
1414
(7)
(6)
Payment of a claim is considered made on the date
1415 the payment was mailed or electronically transferred
to the

1416
provider
. An overdue payment of a claim bears simple interest of
1417
15

12
percent per year
, to be calculated on the full total

1418
amount that should have been paid on the claim within the

1419
applicable time period specified in this section. If an

1420
applicable court, arbitration tribunal, or other binding legal

1421
process determines that a claim that was paid at a lesser amount

1422
should have been paid at a full total amount, whether under a

1423
breach of contract legal claim, a legal claim under a statutory

1424
private cause of action, or other basis, the 15 percent per year

1425
interest must be calculated on the full total amount, rather

1426
than upon the difference between the full total amount and the

1427
amount that was actually paid. If an applicable court,

1428
arbitration tribunal, or other binding legal process determines

1429
that a claim was subject to an inappropriate or impermissible

1430
denial or partial denial, whether in a breach of contract,

1431
statute, common law, or otherwise, interest must be calculated

1432
on the full total amount that should have been paid on the claim

1433
within the applicable time period for payment specified in this

1434
section, and the act of denial or partial denial is deemed not

1435
to have in any way tolled the time period for such payment
.
1436 Interest on
the full total amount that should have been paid on

1437
the claim within the applicable time period specified in this

1438
section

an overdue payment for a claim or for any portion of a

1439
claim
begins to accrue when the claim should have been paid
,

1440
denied, or contested
. The interest
must be paid along with, and

1441
in addition to, the payment for the satisfaction of the full

1442
total amount of the claim, as determined by an applicable court,

1443
arbitration tribunal, or other binding legal process

is payable

1444
with the payment of the claim
.
1445
(8)
(7)
For all contracts entered into or renewed on or
1446 after October 1, 2002, a health maintenance organization’s
1447 internal dispute resolution process related to a denied claim
1448 not under active review by a mediator, arbitrator, or third
1449 party dispute entity must be finalized within 60 days after the
1450 receipt of the provider’s request for review or appeal.
1451
Notwithstanding any provision of this section, if the provider

1452
and health maintenance organization disagree as to the

1453
interpretation of contractual or statutory language, the

1454
provider is not required to participate in the health

1455
maintenance organization’s internal dispute resolution process.

1456
(9)
(8)
A provider or any representative of a provider,
1457 regardless of whether the provider is under contract with the
1458 health maintenance organization,
is prohibited from collecting

1459
or attempting

may not collect or attempt
to collect money from,
1460
maintaining

maintain
any action at law against, or
reporting

1461
report
to a credit agency
an enrollee

a subscriber
for payment
1462 of covered services for which the health maintenance
1463 organization contested or denied the provider’s claim. This
1464 prohibition applies during the pendency of any claim for payment
1465 made by the provider to the health maintenance organization for
1466 payment of the services or internal dispute resolution process
1467 to determine whether the health maintenance organization is
1468 liable for the services. For a claim, this pendency applies from
1469 the date the claim or a portion of the claim is denied to the
1470 date of the completion of the health maintenance organization’s
1471 internal dispute resolution process, not to exceed 60 days. This
1472 subsection does not prohibit collection by the provider of
1473 copayments, coinsurance, or deductible amounts due the provider.
1474
(9)

The provisions of this section may not be waived,

1475
voided, or nullified by contract.

1476 (10) A health maintenance organization
is prohibited from

1477
retrospectively denying

may not retroactively deny
a claim
1478 because of
enrollee

subscriber
ineligibility more than
90 days

1

1479
year
after the date of payment of the claim.
1480 (11) A health maintenance organization
must

shall
pay a
1481 contracted primary care or admitting physician, pursuant to such
1482 physician’s contract, for providing inpatient services in a
1483 contracted hospital to
an enrollee

a subscriber
if such services
1484 are determined by the
primary care physician or admitting

1485
physician

health maintenance organization
to be medically
1486 necessary and
such services are
covered services under the
1487 health maintenance organization’s contract with the contract
1488 holder.
1489 (12) A permissible error ratio of 5 percent is established
1490 for health maintenance organizations’ claims payment violations
1491 of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c),
1492 and (e). If the error ratio of a particular
health maintenance

1493
organization

insurer
does not exceed the permissible error ratio
1494 of 5 percent for an audit period, no fine
may

shall
be assessed
1495 for the noted claims violations for the audit period. The error
1496 ratio
is

shall be
determined by dividing the number of claims
1497 with violations found on a statistically valid sample of claims
1498 for the audit period by the total number of claims in the
1499 sample. If the error ratio exceeds the permissible error ratio
1500 of 5 percent, a fine may be assessed according to s. 624.4211
1501 for those claims payment violations which exceed the error
1502 ratio. Notwithstanding the provisions of this section, the
1503 office may fine a health maintenance organization for claims
1504 payment violations of paragraphs (3)(e) and (4)(e) which create
1505 an uncontestable obligation to pay the claim
as submitted by the

1506
provider
. The office shall
refrain from imposing a

not
fine
upon

1507
a health maintenance organization

organizations
for violations
1508 which the office determines were due to circumstances beyond the
1509 organization’s control.
1510 (13) This section
applies

shall apply
to all claims or any
1511 portion of a claim submitted
for payment for services provided

1512
to an enrollee

by
a
health maintenance organization subscriber

1513 under a health maintenance organization
plan, or submitted for

1514
payment for services provided to an enrollee under a self

1515
insured plan or fund, or fully-insured plan or fund, offered by

1516
a person or an entity, when a health maintenance organization is

1517
involved in the administration, or claims-processing activities,

1518
relating to such plan or fund

subscriber contract to the

1519
organization for payment
.
1520 (14) Notwithstanding paragraph (3)(b), where an electronic
1521 pharmacy claim is submitted to a pharmacy benefits manager
1522 acting on behalf of a health maintenance organization, the
1523 pharmacy benefits manager
must

shall
, within 30 days
after

of

1524 receipt of the claim, pay the claim or notify a provider or
1525 designee if a claim is denied or contested. Notice of the
health

1526
maintenance
organization’s action on the claim and payment of
1527 the claim is considered to be made on the date the notice or
1528 payment was
received by the provider

mailed
or electronically
1529 transferred.
1530 (15) Notwithstanding paragraph (4)(a), effective November
1531 1, 2003, where a nonelectronic pharmacy claim is submitted to a
1532 pharmacy benefits manager acting on behalf of a health
1533 maintenance organization, the pharmacy benefits manager shall
1534 provide acknowledgment of receipt of the claim within 30 days
1535 after receipt of the claim to the provider or provide a provider
1536 within 30 days after receipt with electronic access to the
1537 status of a submitted claim.
1538 (16) Notwithstanding the
18-month

30-month
period provided
1539 in subsection
(6)

(5)
, all claims for overpayment submitted to a
1540 provider licensed under
chapter 395,
chapter 458, chapter 459,
1541 chapter 460, chapter 461,
chapter 463,
chapter 466, or chapter
1542 490 must be submitted to the provider within 12 months after the
1543 health maintenance organization’s payment of the claim.
An

1544
overpayment

A
claim
to a provider licensed under chapter 395,

1545
458, chapter 459, chapter 460, chapter 461, chapter 463, chapter

1546
466, or chapter 490 is prohibited

for overpayment may not be

1547
permitted
beyond 12 months after the health maintenance
1548 organization’s payment of a claim, except that claims for
1549 overpayment may be sought beyond that time from providers
1550 convicted of fraud pursuant to s. 817.234.
1551 (17) Notwithstanding any other provision of this section,
1552 all claims for underpayment from a provider licensed under
1553
chapter 395,
chapter 458, chapter 459, chapter 460, chapter 461,
1554 or chapter 466 must be submitted to the health maintenance
1555 organization within 12 months after the health maintenance
1556 organization’s payment of the claim. A claim for underpayment
by

1557
a provider licensed under chapter 395, chapter 458, chapter 459,

1558
chapter 460, chapter 461, or chapter 466 is prohibited

may not

1559
be permitted
beyond 12 months after the health maintenance
1560 organization’s payment of a claim.
1561
(18)

Nothing in this section may be interpreted to limit,

1562
restrict, or negatively impact any legal claim by a provider or

1563
health maintenance organization for breach of contract,

1564
statutory or regulatory violation, or a common-law cause of

1565
action, nor to shorten or otherwise negatively impact the

1566
statute of limitations timeframe for bringing any such legal

1567
claim.

1568
(19)

A health insurer is prohibited from requesting

1569
information from a contracted or noncontracted provider which

1570
does not apply to the medical condition at issue for the

1571
purposes of adjudicating a clean claim.

1572
(20)

A health maintenance organization is prohibited from

1573
requesting a contracted or noncontracted provider to resubmit

1574
claim information that the contracted or noncontracted provider

1575
can document it has already provided to the health maintenance

1576
organization or that is contained inside the electronic medical

1577
record to which the health maintenance organization has been

1578
provided access.

1579
(21)

Notwithstanding any other provision of this section, a

1580
health maintenance organization is prohibited from requiring any

1581
information from a provider before the provision of emergency

1582
health care services as a condition of payment of a claim, as a

1583
basis for denying, delaying, offsetting, withholding, or

1584
reducing payment of a claim, or in contesting whether the claim

1585
is a clean claim.

1586
(22)

For a violation of this section, a provider shall have

1587
a private cause of action to proceed against the health

1588
maintenance organization in the applicable tribunal for the

1589
violation.

1590 Section 5. Paragraph (c) of subsection (2) of section
1591 395.1065, Florida Statutes, is amended to read:
1592 395.1065 Criminal and administrative penalties;
1593 moratorium.—
1594 (2)
1595 (c) The agency may impose an administrative fine for the
1596 violation of s. 641.3154 or, if sufficient claims due to a
1597 provider from a health maintenance organization do not exist to
1598 enable the take-back of an overpayment, as provided under
s.

1599
641.3155(6)

s. 641.3155(5)
, for the violation of
s. 641.3155(6)

1600
s. 641.3155(5)
. The administrative fine for a violation cited in
1601 this paragraph shall be in the amounts specified in s.
1602 641.52(5), and the provisions of paragraph (a) do not apply.
1603 Section 6. This act shall take effect July 1, 2026.