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2011 Florida Statutes

SECTION 64731
Leasing, renting, or granting access to a participating provider.
F.S. 627.64731
627.64731 Leasing, renting, or granting access to a participating provider.
(1) As used in this section, the term:
(a) “Contracting entity” means any person or entity that is engaged in the act of contracting with participating providers and has a direct contract with a participating provider for the delivery of health care services or the selling or assigning of physicians or physician panels to other health care entities.
(b) “Participating provider” means a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466, or a physician group practice that has a health care contract with a contracting entity and is entitled to reimbursement for health care services rendered to an enrollee under the health care contract and includes both preferred providers as defined in s. 627.6471 and exclusive providers as defined in s. 627.6472.
(2) A contracting entity may not sell, lease, rent, or otherwise grant access to the health care services of a participating provider under a health care contract unless expressly authorized by the health care contract. The health care contract must specifically provide that it applies to network rental arrangements and state that one purpose of the contract is selling, renting, or giving the contracting entity rights to the services of the participating provider, including other preferred provider organizations. At the time a health care contract is entered into with a participating provider, the contracting entity shall, to the extent possible, identify any third party to which the contracting entity has granted access to the health care services of the participating provider. The contracting entity may sell, lease, rent, or otherwise grant access to the participating provider’s services only to a third party that is:
(a) A payor or a third-party administrator or other entity responsible for administering claims on behalf of the payor;
(b) A preferred provider organization or preferred provider network that receives access to the participating provider’s services pursuant to an arrangement with the preferred provider organization or preferred provider network in a contract with the participating provider and that is required to comply with all of the terms, conditions, and affirmative obligations to which the originally contracted primary participating provider network is bound under its contract with the participating provider, including, but not limited to, obligations concerning patient steerage and the timeliness and manner of reimbursement; or
(c) An entity that is engaged in the business of providing electronic claims transport between the contracting entity and the payor or third-party administrator and that complies with all of the applicable terms, conditions, and affirmative obligations of the contracting entity’s contract with the participating provider including, but not limited to, obligations concerning patient steerage and the timeliness and manner of reimbursement.
(3) Upon a request by a participating provider, a contracting entity must provide the identity of any third party that has been granted access to the health care services of the participating provider.
(4) A contracting entity that leases, rents, or otherwise grants access to the health care services of a participating provider must maintain an Internet website or a toll-free telephone number through which the provider may obtain a listing, updated at least every 90 days, of the third parties that have been granted access to the provider’s health care services.
(5) A contracting entity that leases, rents, or otherwise grants access to a participating provider’s health care services must ensure that an explanation of benefits or remittance advice furnished to the participating provider that delivers health care services under the health care contract identifies the contractual source of any applicable discount.
(6) Subject to applicable continuity-of-care laws, the right of a third party to exercise the rights and responsibilities of a contracting entity under a health care contract terminates on the day following the termination of the participating provider’s contract with the contracting entity.
(7) The provisions of this section do not apply if the third party that is granted access to a participating provider’s health care services under a health care contract is:
(a) An employer or other entity providing coverage for health care services to the employer’s employees or the entity’s members and the employer or entity has a contract with the contracting entity or the contracting entity’s affiliate for the administration or processing of claims for payment or services provided under the health care contract;
(b) An entity providing administrative services to, or receiving administrative services from, the contracting entity or the contracting entity’s affiliate or subsidiary; or
(c) An affiliate or a subsidiary of a contracting entity, or other entity if operating under the same brand licensee program as the contracting entity.
(8) A health care contract may provide for arbitration of disputes arising under this section.
(9) A contracting entity shall ensure that all third parties to which the contracting entity has sold, rented, assigned, or otherwise given access to the participating provider’s discounted rate comply with the physician contract, including all requirements to encourage access to the participating provider, and pay the provider pursuant to the rates of payment and methodology set forth in that contract, unless otherwise agreed to by a participating provider.
(10) A contracting entity is deemed in compliance with this section when the insured’s identification card provides information, written or electronically, which identifies the preferred provider network or networks to be used to reimburse the provider for covered services.
(11) This section does not apply to a contract between a contracting entity and a discount medical plan organization licensed or exempt under part II of chapter 636.
History.s. 4, ch. 2008-212.