Florida Senate - 2024 COMMITTEE AMENDMENT
Bill No. SB 892
Ì6423562Î642356
LEGISLATIVE ACTION
Senate . House
Comm: RCS .
02/08/2024 .
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The Committee on Banking and Insurance (Harrell) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 90 - 307
4 and insert:
5 has consented to the fee.
6 (d) This subsection may not be waived, voided, or nullified
7 by contract, and any contractual clause in conflict with this
8 subsection or that purports to waive any requirements of this
9 subsection is null and void.
10 (e) The office has all rights and powers to enforce this
11 subsection as provided by s. 624.307.
12 (f) The commission may adopt rules to implement this
13 subsection.
14 (21)(a) A health insurer may not deny any claim
15 subsequently submitted by a dentist licensed under chapter 466
16 for procedures specifically included in a prior authorization
17 unless at least one of the following circumstances applies for
18 each procedure denied:
19 1. Benefit limitations, such as annual maximums and
20 frequency limitations not applicable at the time of the prior
21 authorization, are reached subsequent to issuance of the prior
22 authorization.
23 2. The documentation provided by the person submitting the
24 claim fails to support the claim as originally authorized.
25 3. Subsequent to the issuance of the prior authorization,
26 new procedures are provided to the patient or a change in the
27 condition of the patient occurs such that the prior authorized
28 procedure would no longer be considered medically necessary,
29 based on the prevailing standard of care.
30 4. Subsequent to the issuance of the prior authorization,
31 new procedures are provided to the patient or a change in the
32 patient’s condition occurs such that the prior authorized
33 procedure would at that time have required disapproval pursuant
34 to the terms and conditions for coverage under the patient’s
35 plan in effect at the time the prior authorization was issued.
36 5. The denial of the claim was due to one of the following:
37 a. Another payor is responsible for payment.
38 b. The dentist has already been paid for the procedures
39 identified in the claim.
40 c. The claim was submitted fraudulently, or the prior
41 authorization was based in whole or material part on erroneous
42 information provided to the health insurer by the dentist,
43 patient, or other person not related to the insurer.
44 d. The person receiving the procedure was not eligible to
45 receive the procedure on the date of service and the health
46 insurer did not know, and with the exercise of reasonable care
47 could not have known, of his or her ineligibility.
48 (b) This subsection may not be waived, voided, or nullified
49 by contract, and any contractual clause in conflict with this
50 subsection or that purports to waive any requirements of this
51 subsection is null and void.
52 (c) The office has all rights and powers to enforce this
53 subsection as provided by s. 624.307.
54 (d) The commission may adopt rules to implement this
55 subsection.
56 Section 2. Subsection (2) of section 627.6474, Florida
57 Statutes, is amended to read:
58 627.6474 Provider contracts.—
59 (2) A contract between a health insurer and a dentist
60 licensed under chapter 466 for the provision of services to an
61 insured may not contain a provision that requires the dentist to
62 provide services to the insured under such contract at a fee set
63 by the health insurer unless such services are covered services
64 under the applicable contract. As used in this subsection, the
65 term “covered services” means dental care services for which a
66 reimbursement is available under the insured’s contract,
67 notwithstanding or for which a reimbursement would be available
68 but for the application of contractual limitations such as
69 deductibles, coinsurance, waiting periods, annual or lifetime
70 maximums, frequency limitations, alternative benefit payments,
71 or any other limitation.
72 Section 3. Section 636.032, Florida Statutes, is amended to
73 read:
74 636.032 Acceptable payments.—
75 (1) Each prepaid limited health service organization may
76 accept from government agencies, corporations, groups, or
77 individuals payments covering all or part of the cost of
78 contracts entered into between the prepaid limited health
79 service organization and its subscribers.
80 (2)(a) A contract between a prepaid limited health service
81 organization and a dentist licensed under chapter 466 for the
82 provision of services to a subscriber may not specify credit
83 card payment as the only acceptable method for payments from the
84 prepaid limited health service organization to the dentist.
85 (b) At least 10 days before a limited health service
86 organization pays a claim to a dentist through electronic funds
87 transfer, including, but not limited to, virtual credit card
88 payments, the prepaid limited health service organization shall
89 notify the dentist in writing of all of the following:
90 1. The fees, if any, that are associated with the
91 electronic funds transfer.
92 2. The available methods of payment of claims by the
93 prepaid limited health service organization, with clear
94 instructions to the dentist on how to select an alternative
95 payment method.
96 (c) A prepaid limited health service organization that pays
97 a claim to a dentist through Automatic Clearing House (ACH)
98 transfer may not charge a fee solely to transmit the payment to
99 the dentist unless the dentist has consented to the fee.
100 (d) This subsection may not be waived, voided, or nullified
101 by contract, and any contractual clause in conflict with this
102 subsection or that purports to waive any requirements of this
103 subsection is null and void.
104 (e) The office has all rights and powers to enforce this
105 subsection as provided by s. 624.307.
106 (f) The commission may adopt rules to implement this
107 subsection.
108 Section 4. Subsection (13) of section 636.035, Florida
109 Statutes, is amended, and subsection (15) is added to that
110 section, to read:
111 636.035 Provider arrangements.—
112 (13) A contract between a prepaid limited health service
113 organization and a dentist licensed under chapter 466 for the
114 provision of services to a subscriber of the prepaid limited
115 health service organization may not contain a provision that
116 requires the dentist to provide services to the subscriber of
117 the prepaid limited health service organization at a fee set by
118 the prepaid limited health service organization unless such
119 services are covered services under the applicable contract. As
120 used in this subsection, the term “covered services” means
121 dental care services for which a reimbursement is available
122 under the subscriber’s contract, notwithstanding or for which a
123 reimbursement would be available but for the application of
124 contractual limitations such as deductibles, coinsurance,
125 waiting periods, annual or lifetime maximums, frequency
126 limitations, alternative benefit payments, or any other
127 limitation.
128 (15)(a) A prepaid limited health service organization may
129 not deny any claim subsequently submitted by a dentist licensed
130 under chapter 466 for procedures specifically included in a
131 prior authorization unless at least one of the following
132 circumstances applies for each procedure denied:
133 1. Benefit limitations, such as annual maximums and
134 frequency limitations not applicable at the time of the prior
135 authorization, are reached subsequent to issuance of the prior
136 authorization.
137 2. The documentation provided by the person submitting the
138 claim fails to support the claim as originally authorized.
139 3. Subsequent to the issuance of the prior authorization,
140 new procedures are provided to the patient or a change in the
141 condition of the patient occurs such that the prior authorized
142 procedure would no longer be considered medically necessary,
143 based on the prevailing standard of care.
144 4. Subsequent to the issuance of the prior authorization,
145 new procedures are provided to the patient or a change in the
146 patient’s condition occurs such that the prior authorized
147 procedure would at that time have required disapproval pursuant
148 to the terms and conditions for coverage under the patient’s
149 plan in effect at the time the prior authorization was issued.
150 5. The denial of the dental service claim was due to one of
151 the following:
152 a. Another payor is responsible for payment.
153 b. The dentist has already been paid for the procedures
154 identified in the claim.
155 c. The claim was submitted fraudulently, or the prior
156 authorization was based in whole or material part on erroneous
157 information provided to the prepaid limited health service
158 organization by the dentist, patient, or other person not
159 related to the organization.
160 d. The person receiving the procedure was not eligible to
161 receive the procedure on the date of service and the prepaid
162 limited health service organization did not know, and with the
163 exercise of reasonable care could not have known, of his or her
164 ineligibility.
165 (b) This subsection may not be waived, voided, or nullified
166 by contract, and any contractual clause in conflict with this
167 subsection or that purports to waive any requirements of this
168 subsection is null and void.
169 (c) The office has all rights and powers to enforce this
170 subsection as provided by s. 624.307.
171 (d) The commission may adopt rules to implement this
172 subsection.
173 Section 5. Subsection (11) of section 641.315, Florida
174 Statutes, is amended, and subsections (13) and (14) are added to
175 that section, to read:
176 641.315 Provider contracts.—
177 (11) A contract between a health maintenance organization
178 and a dentist licensed under chapter 466 for the provision of
179 services to a subscriber of the health maintenance organization
180 may not contain a provision that requires the dentist to provide
181 services to the subscriber of the health maintenance
182 organization at a fee set by the health maintenance organization
183 unless such services are covered services under the applicable
184 contract. As used in this subsection, the term “covered
185 services” means dental care services for which a reimbursement
186 is available under the subscriber’s contract, notwithstanding or
187 for which a reimbursement would be available but for the
188 application of contractual limitations such as deductibles,
189 coinsurance, waiting periods, annual or lifetime maximums,
190 frequency limitations, alternative benefit payments, or any
191 other limitation.
192 (13)(a) A contract between a health maintenance
193 organization and a dentist licensed under chapter 466 for the
194 provision of services to a subscriber of the health maintenance
195 organization may not specify credit card payment as the only
196 acceptable method for payments from the health maintenance
197 organization to the dentist.
198 (b) At least 10 days before a health maintenance
199 organization pays a claim to a dentist through electronic funds
200 transfer, including, but not limited to, virtual credit card
201 payments, the health maintenance organization shall notify the
202 dentist in writing of all of the following:
203 1. The fees, if any, that are associated with the
204 electronic funds transfer.
205 2. The available methods of payment of claims by the health
206 maintenance organization, with clear instructions to the dentist
207 on how to select an alternative payment method.
208 (c) A health maintenance organization that pays a claim to
209 a dentist through Automated Clearing House (ACH) transfer may
210 not charge a fee solely to transmit the payment to the dentist
211 unless the dentist has consented to the fee.
212
213 ================= T I T L E A M E N D M E N T ================
214 And the title is amended as follows:
215 Delete lines 11 - 58
216 and insert:
217 providing construction; authorizing the Office of
218 Insurance Regulation of the Financial Services
219 Commission to enforce certain provisions; authorizing
220 the commission to adopt rules; prohibiting a health
221 insurer from denying claims for procedures included in
222 a prior authorization; providing exceptions; providing
223 construction; authorizing the office to enforce
224 certain provisions; authorizing the commission to
225 adopt rules; amending s. 627.6474, F.S.; revising the
226 definition of the term “covered services”; amending s.
227 636.032, F.S.; prohibiting a contract between a
228 prepaid limited health service organization and a
229 dentist from containing certain restrictions on
230 payment methods; requiring the prepaid limited health
231 service organization to make certain notifications
232 before paying a claim to a dentist through electronic
233 funds transfer; prohibiting a prepaid limited health
234 service organization from charging a fee to transmit a
235 payment to a dentist through ACH transfer unless the
236 dentist has consented to such fee; providing
237 construction; authorizing the office to enforce
238 certain provisions; authorizing the commission to
239 adopt rules; amending s. 636.035, F.S.; revising the
240 definition of the term “covered services”; prohibiting
241 a prepaid limited health service organization from
242 denying claims for procedures included in a prior
243 authorization; providing exceptions; providing
244 construction; authorizing the office to enforce
245 certain provisions; authorizing the commission to
246 adopt rules; amending s. 641.315, F.S.; revising the
247 definition of the term “covered service”; prohibiting
248 a contract between a health maintenance organization
249 and a dentist from containing certain restrictions on
250 payment methods; requiring the health maintenance
251 organization to make certain notifications before
252 paying a claim to a dentist through electronic funds
253 transfer; prohibiting a health maintenance
254 organization from charging a fee to transmit a payment
255 to a dentist through ACH transfer unless the dentist
256 has consented to such fee; providing construction;