House Bill hb1235
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
By Representative Benson
1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 627.4235, F.S.; providing for payments of
4 benefits under multiple health insurance
5 policies regardless of certain timeframes;
6 amending s. 627.613, F.S.; defining the term
7 "clean claim" for purposes of health insurance
8 claims made by a provider under contract with a
9 health insurer; requiring payment within
10 specified periods; requiring the payment of
11 interest on overdue payments; providing payment
12 procedures; requiring the Department of
13 Insurance to adopt rules prescribing forms;
14 requiring the use of standard code sets;
15 creating s. 627.6135, F.S.; defining the term
16 "emergency medical condition"; prohibiting a
17 health insurer from placing certain
18 requirements or limits on the provision of
19 emergency services; providing for determining
20 whether an emergency medical condition exists;
21 providing requirements for providing emergency
22 care and treatment; amending s. 641.19, F.S.;
23 defining the term "emergency medical condition"
24 for purposes of part I of ch. 641, F.S.,
25 relating to health maintenance organizations;
26 amending s. 641.315, F.S.; providing that a
27 contract is unenforceable to the extent that it
28 conflicts with part I of ch. 641, F.S.;
29 amending s. 641.3155, F.S.; providing
30 procedures for the payment of claims; requiring
31 payment within specified periods; requiring the
1
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 payment of interest on overdue payments;
2 requiring the coordination of benefits;
3 amending s. 641.3156, F.S.; specifying that
4 certain authorizations for service are binding
5 upon the health maintenance organization;
6 amending s. 641.495, F.S.; providing
7 requirements for issuing treatment
8 authorizations; amending s. 408.7057, F.S.;
9 redefining the term "managed care
10 organization"; providing requirements for
11 filing a claim dispute with a resolution
12 organization; providing an effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Subsection (2) of section 627.4235, Florida
17 Statutes, is amended to read:
18 627.4235 Coordination of benefits.--
19 (2) A hospital, medical, or surgical expense policy,
20 health care services plan, or self-insurance plan that
21 provides protection or insurance against hospital, medical, or
22 surgical expenses issued in this state or issued for delivery
23 in this state may contain a provision whereby the insurer may
24 reduce or refuse to pay benefits otherwise payable thereunder
25 solely on account of the existence of similar benefits
26 provided under insurance policies issued by the same or
27 another insurer, health care services plan, or self-insurance
28 plan which provides protection or insurance against hospital,
29 medical, or surgical expenses only if, as a condition of
30 coordinating benefits with another insurer, the insurers
31 together pay 100 percent of the total covered reasonable
2
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 expenses actually incurred of the type of expense within the
2 benefits described in the policies and presented to the
3 insurer for payment, regardless of any timeframes for payment
4 or filing of claims established by any applicable contract.
5 Section 2. Section 627.613, Florida Statutes, is
6 amended to read:
7 (Substantial rewording of section. See
8 s. 627.613, F.S., for present text.)
9 627.613 Time of payment of claims.--
10 (1)(a) The term "clean claim" for a noninstitutional
11 provider means a properly and accurately completed paper or
12 electronic billing instrument that consists of the HCFA 1500
13 data set, or its successor, with entries stated as mandatory
14 by the United States Secretary of Health and Human Services.
15 Such claim does not involve coordination of benefits for
16 third-party liability or subrogation, as evidenced by the
17 information provided on the claim form related to coordination
18 of benefits.
19 (b) The term "clean claim" for an institutional
20 provider means a properly and accurately completed paper or
21 electronic billing instrument that consists of the UB-92 data
22 set, or its successor, with entries stated as mandatory by the
23 National Uniform Billing Committee. It does not involve
24 coordination of benefits for third-party liability or
25 subrogation, as evidenced by the information provided on the
26 claim form related to coordination of benefits.
27 (2)(a) A health insurer shall pay any clean claim or
28 any portion of a clean claim made by a contract provider for
29 services or goods provided under a contract with the health
30 insurer, or a clean claim made by a noncontract provider which
31 the insurer does not contest or deny, within 45 days after
3
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 receipt of the claim by the health insurer which is mailed or
2 electronically transferred by the provider.
3 (b) A health insurer that denies or contests a
4 provider's claim or any portion of a claim must notify the
5 provider, in writing, within 45 days after the health insurer
6 receives the claim that the claim is contested or denied. The
7 notice that the claim is denied or contested must identify the
8 contested portion of the claim and the specific reason for
9 contesting or denying the claim, and, if contested, must
10 include a request for additional information. If the provider
11 submits additional information, the provider must, within 35
12 days after receipt of the request, mail or electronically
13 transfer the information to the health insurer. The health
14 insurer shall pay or deny the claim or portion of the claim
15 within 45 days after receipt of the information.
16 (3) Payment of a claim is considered made on the date
17 the payment was received, electronically transferred, or
18 otherwise delivered. Interest on an overdue payment for a
19 clean claim, or for any uncontested portion of a clean claim,
20 begins to accrue on the 45th day after the date the claim is
21 received, according to the following schedule:
22 (a) For a claim that is paid between 45 days and 60
23 days after the date the claim was received by the health
24 maintenance organization, interest accrues at a rate of 10
25 percent per year;
26 (b) For a claim that is paid between 61 days and 90
27 days after the date the claim was received by the health
28 maintenance organization, interest accrues at a rate of 12
29 percent per year;
30 (c) For a claim that is paid between 91 days and 120
31 days after the date the claim was received by the health
4
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 maintenance organization, interest accrues at a rate of 15
2 percent per year; and
3 (d) For a claim that is paid more than 120 days after
4 the date the claim was received by the health maintenance
5 organization, interest accrues at a rate of 18 percent per
6 year.
7
8 The interest must be included with the payment of the claim.
9 Failure to include the interest with payment of the claim is a
10 violation of s. 624.4211.
11 (4) A health insurer must pay or deny a claim not
12 later than 120 days after receiving the claim. Failure to do
13 so creates an uncontestable obligation for the health insurer
14 to pay the claim to the provider.
15 (5) If, as a result of retroactive review of a
16 coverage decision or payment level, a health insurer finds
17 that it has made an overpayment to a provider for services
18 rendered to a subscriber, the organization may not reduce
19 payment to that provider for other services.
20 (6) If the claim has been electronically transmitted
21 to the health insurer, a provider's claim for payment shall be
22 considered received by the health insurer on the date receipt
23 is verified electronically or, if the claim is mailed to the
24 address disclosed by the organization, on the date indicated
25 on the return receipt. A provider may not submit a duplicate
26 claim until 45 days following receipt of a claim.
27 (7) A provider, or the provider's designee, who bills
28 electronically must be provided with an electronic
29 acknowledgment of the receipt of a claim within 72 hours.
30
31
5
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 (8) A health insurer may not retroactively deny a
2 claim because of subscriber ineligibility more than 1 year
3 after the date of payment of a clean claim.
4 (9) A health insurer may not delay payment on a claim
5 from a physician, hospital, or other provider while waiting
6 for the submission of a claim from another physician,
7 hospital, or other provider for services provided during the
8 same episode of illness. A health insurer may not deny or
9 withhold payment on a claim because the insured has not paid a
10 required deductible or copayment.
11 (10) The department shall adopt rules to establish
12 claim forms that are consistent with federal claim-filing
13 standards required by the United States Secretary of Health
14 and Human Services. The department shall adopt rules to
15 establish coding standards that are consistent with Medicare
16 coding standards adopted by the United States Secretary of
17 Health and Human Services. The coding standards shall apply to
18 both electronic and paper claims.
19 (11) All providers and payers shall use the standard
20 code sets defined for their area of operation by the United
21 States Secretary of Health and Human Services. Unless
22 otherwise defined by the secretary, the effective date for
23 code changes shall be consistent with those adopted by the
24 Medicare contractor, intermediary or carrier, and must include
25 grace periods established by the contractor.
26 (12) A provision in a provider contract is void and
27 unenforceable to the extent that it purports to waive or
28 preclude the rights, remedies, or requirements set forth in
29 this part.
30 Section 3. Section 627.6135, Florida Statutes, is
31 created to read:
6
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 627.6135 Requirements for providing emergency services
2 and care.--
3 (1) As used in this section, the term "emergency
4 medical condition" means:
5 (a) A medical condition manifesting itself by acute
6 symptoms of sufficient severity, which may include severe
7 pain, psychiatric disturbances, symptoms of substance abuse,
8 or other acute symptoms, such that the absence of immediate
9 medical attention could reasonably be expected to result in
10 any of the following:
11 1. Serious jeopardy to the health of a patient,
12 including a pregnant woman or a fetus.
13 2. Serious impairment to bodily functions.
14 3. Serious dysfunction of any bodily organ or part.
15 (b) With respect to a pregnant woman:
16 1. That there is inadequate time to effect safe
17 transfer to another hospital prior to delivery;
18 2. That a transfer may pose a threat to the health and
19 safety of the patient or fetus; or
20 3. That there is evidence of the onset and persistence
21 of uterine contractions or rupture of the membranes.
22 (2) In providing for emergency services and care as a
23 covered service, a health insurer may not:
24 (a) Require prior authorization for the receipt of
25 prehospital transport or treatment or for emergency services
26 and care.
27 (b) Indicate that emergencies are covered only if care
28 is secured within a certain period of time.
29 (c) Use terms such as "life threatening" or "bona
30 fide" to qualify the kind of emergency that is covered.
31
7
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 (d) Deny payment based on the subscriber's failure to
2 notify the health insurer in advance of seeking treatment or
3 within a certain period after the care is given.
4 (3) Prehospital and hospital-based trauma services and
5 emergency services and care must be provided to an insured as
6 required under ss. 395.1041, 395.4045, and 401.45.
7 (4)(a) When an insured is present at a hospital
8 seeking emergency services and care, the determination as to
9 whether an emergency medical condition exists shall be made,
10 for the purposes of treatment, by a physician of the hospital
11 or, to the extent permitted by applicable law, by other
12 appropriate licensed professional hospital personnel under the
13 supervision of the hospital physician. The physician or the
14 appropriate personnel shall indicate in the patient's chart
15 the results of the screening, examination, and evaluation. The
16 health insurer shall compensate the provider for the
17 screening, evaluation, and examination that is reasonably
18 calculated to assist the health care provider in arriving at a
19 determination as to whether the patient's condition is an
20 emergency medical condition. The health insurer shall
21 compensate the provider for emergency services and care. If a
22 determination is made that an emergency medical condition does
23 not exist, payment for services rendered subsequent to that
24 determination is governed by the health insurance policy.
25 (b)1. If a determination has been made that an
26 emergency medical condition exists and the insured has
27 notified the hospital, or the hospital emergency personnel
28 otherwise have knowledge that the patient is insured under a
29 health plan, the hospital must make a reasonable attempt to
30 notify the subscriber's primary care physician, if known, or
31 the health plan, if the health plan had previously requested
8
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 in writing that the notification be made directly to the
2 health plan, of the existence of the emergency medical
3 condition. If the primary care physician is not known, or has
4 not been contacted, the hospital must:
5 a. Notify the health plan as soon as possible; or
6 b. Notify the health plan within 24 hours or on the
7 next business day after admission of the subscriber as an
8 inpatient to the hospital.
9 2. If notification required by this paragraph is not
10 accomplished, the hospital must document its attempts to
11 notify the health insurer of the circumstances that precluded
12 attempts to notify the health insurer. A health insurer may
13 not deny payment for emergency services and care based on a
14 hospital's failure to comply with the notification
15 requirements of this paragraph. This paragraph does not alter
16 any contractual responsibility of an insured to make contact
17 with a health insurer, subsequent to receiving treatment for
18 the emergency medical condition.
19 (c) If the insured's primary care physician responds
20 to the notification, the hospital physician and the primary
21 care physician may discuss the appropriate care and treatment
22 of the subscriber. The health insurer may have a member of the
23 hospital staff with whom it has a contract participate in the
24 treatment of the insured within the scope of the physician's
25 hospital staff privileges. Notwithstanding any other state
26 law, a hospital may request and collect insurance or financial
27 information from a patient, in accordance with federal law,
28 which is necessary to determine if the patient has health
29 insurance, if emergency services and care are not thereby
30 delayed.
31
9
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 Section 4. Paragraph (a) of subsection (7) of section
2 641.19, Florida Statutes, is amended to read:
3 641.19 Definitions.--As used in this part, the term:
4 (7) "Emergency medical condition" means:
5 (a) A medical condition manifesting itself by acute
6 symptoms of sufficient severity, which may include severe
7 pain, psychiatric disturbances, symptoms of substance abuse,
8 or other acute symptoms, such that the absence of immediate
9 medical attention could reasonably be expected to result in
10 any of the following:
11 1. Serious jeopardy to the health of a patient,
12 including a pregnant woman or a fetus.
13 2. Serious impairment to bodily functions.
14 3. Serious dysfunction of any bodily organ or part.
15 Section 5. Subsection (10) is added to section
16 641.315, Florida Statutes, to read:
17 641.315 Provider contracts.--
18 (10) A provision in a provider contract is void and
19 unenforceable to the extent that it purports to waive or
20 preclude the rights, remedies, or requirements set forth in
21 this part.
22 Section 6. Subsections (1) and (3) of section
23 641.3155, Florida Statutes, are amended, and subsection (11)
24 is added to that section, to read:
25 641.3155 Payment of claims.--
26 (1)(a) As used in this section, the term "clean claim"
27 for a noninstitutional provider means a claim submitted on a
28 HCFA 1500 for a physician licensed under chapter 458 or
29 chapter 459 or other appropriate form for any other
30 noninstitutional provider which has no defect or impropriety,
31 including lack of required substantiating documentation for
10
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 noncontracted providers and suppliers, or particular
2 circumstances requiring special treatment which prevent timely
3 payment from being made on the claim. A claim may not be
4 considered not clean solely because a health maintenance
5 organization refers the claim to a medical specialist within
6 the health maintenance organization for examination. If
7 additional substantiating documentation, such as the medical
8 record or encounter data, is required from a source outside
9 the health maintenance organization, the claim is considered
10 not clean. This definition of "clean claim" is repealed on the
11 effective date of rules adopted by the department which define
12 the term "clean claim."
13 (b) Absent a written definition that is agreed upon
14 through contract, the term "clean claim" for an institutional
15 claim is a properly and accurately completed paper or
16 electronic billing instrument that consists of the UB-92 data
17 set or its successor with entries stated as mandatory by the
18 National Uniform Billing Committee. Such claim does not
19 involve coordination of benefits for third-party liability or
20 subrogation, as evidenced by the information provided on the
21 claim form related to coordination of benefits.
22 (c) The department shall adopt rules to establish
23 claim forms consistent with federal claim-filing standards for
24 health maintenance organizations required by the United States
25 Secretary of Health and Human Services federal Health Care
26 Financing Administration. The department may adopt rules
27 relating to coding standards consistent with Medicare coding
28 standards adopted by the United States Secretary of Health and
29 Human Services federal Health Care Financing Administration.
30 The coding standards apply to both electronic and paper
31 claims.
11
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 (d) All providers and payers shall use the standard
2 code sets defined for their area of operation by the United
3 States Secretary of Health and Human Services. Unless
4 otherwise defined by the secretary, the effective date for
5 code changes shall be consistent with those adopted by the
6 Medicare contractor, intermediary or carrier, and include
7 grace periods established by the contractor.
8 (3) Payment of a claim is considered made on the date
9 the payment was received or electronically transferred or
10 otherwise delivered. An overdue payment of a claim bears
11 simple interest at the rate of 10 percent per year. Interest
12 on an overdue payment for a clean claim or for any uncontested
13 portion of a clean claim begins to accrue on the 36th day
14 after the claim has been received, according to the following
15 schedule:.
16 (a) For a claim that is paid between 36 days and 60
17 days after the date the claim was received by the health
18 maintenance organization, interest accrues at a rate of 10
19 percent per year;
20 (b) For a claim that is paid between 61 days and 90
21 days after the date the claim was received by the health
22 maintenance organization, interest accrues at a rate of 12
23 percent per year;
24 (c) For a claim that is paid between 91 days and 120
25 days after the date the claim was received by the health
26 maintenance organization, interest accrues at a rate of 15
27 percent per year; and
28 (d) For a claim that is paid more than 120 days after
29 the date the claim was received by the health maintenance
30 organization, interest accrues at a rate of 18 percent per
31 year.
12
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1
2 The interest is payable with the payment of the claim.
3 (11)(a) Each policy issued by a health maintenance
4 organization must contain a provision for coordinating
5 benefits under the policy with any similar benefits provided
6 by any other health maintenance organization, group hospital,
7 medical, or surgical expense policy; any group health care
8 services plan; any auto medical policy; any governmental
9 medical expense policy; or any group-type self-insurance plan
10 that provides protection or insurance against hospital,
11 medical, or surgical expenses for the same loss.
12 (b) A policy issued by a health maintenance
13 organization may contain a provision whereby the health
14 maintenance organization may reduce or refuse to pay benefits
15 otherwise payable under the policy solely due to the existence
16 of similar benefits provided under insurance policies issued
17 by the same or another health maintenance organization,
18 insurer, health care services plan, or self-insurance plan if
19 the similar benefits provide protection or insurance against
20 hospital, medical, or surgical expenses only if, as a
21 condition of coordinating benefits with another insurer, 100
22 percent of the total covered benefits described in the
23 policies and presented for payment are paid, regardless of any
24 timeframes for payment or filing of claims established by any
25 applicable contract.
26 Section 7. Subsection (4) is added to section
27 641.3156, Florida Statutes, to read:
28 641.3156 Treatment authorization; payment of claims.--
29 (4) Authorization for a covered service provided by a
30 health maintenance organization's contracted physician for an
31 eligible subscriber is binding upon the health maintenance
13
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 organization, and the health maintenance organization may not
2 deny payment.
3 Section 8. Subsection (4) of section 641.495, Florida
4 Statutes, is amended to read:
5 641.495 Requirements for issuance and maintenance of
6 certificate.--
7 (4)(a) The organization shall ensure that the health
8 care services it provides to subscribers, including physician
9 services as required by s. 641.19(13)(d) and (e), are
10 accessible to the subscribers, with reasonable promptness,
11 with respect to geographic location, hours of operation,
12 provision of after-hours service, and staffing patterns within
13 generally accepted industry norms for meeting the projected
14 subscriber needs. The health maintenance organization must
15 provide treatment authorization 24 hours a day, 7 days a week.
16 Requests for treatment authorization may not be held pending
17 unless the requesting provider contractually agrees to take a
18 pending or tracking number.
19 (b) The organization shall ensure that treatment
20 authorizations are provided 24 hours a day, 7 days a week. A
21 request for treatment authorization must be responded to
22 within 2 hours. Failure to respond within 2 hours waives the
23 right of the health maintenance organization to deny the claim
24 for lack of authorization. A request for treatment
25 authorization may not be held pending unless the requesting
26 provider contractually agrees to take a pending or tracking
27 number.
28 Section 9. Paragraph (a) of subsection (1) and
29 paragraphs (a) and (c) of subsection (2) of section 408.7057,
30 Florida Statutes, are amended to read:
31
14
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 408.7057 Statewide provider and managed care
2 organization claim dispute resolution program.--
3 (1) As used in this section, the term:
4 (a) "Managed care organization" means a health
5 maintenance organization or a prepaid health clinic certified
6 under chapter 641, a prepaid health plan authorized under s.
7 409.912, or an exclusive provider organization certified under
8 s. 627.6472, or a preferred provider organization.
9 (2)(a) The Agency for Health Care Administration shall
10 establish a program by January 1, 2001, to provide assistance
11 to contracted and noncontracted providers and managed care
12 organizations for resolution of claim disputes that are not
13 resolved by the provider and the managed care organization.
14 The agency shall contract with a resolution organizations
15 organization to timely review and consider claim disputes
16 submitted by providers and managed care organizations and
17 recommend to the agency an appropriate resolution of those
18 disputes. The agency shall establish by rule jurisdictional
19 amounts and methods of aggregation for claim disputes that may
20 be considered by the resolution organizations organization.
21 (c) Contracts entered into or renewed on or after
22 October 1, 2000, may require exhaustion of an internal
23 dispute-resolution process as a prerequisite to the submission
24 of a claim by a provider or health maintenance organization to
25 the resolution organization when the dispute-resolution
26 program becomes effective. However, if the internal
27 dispute-resolution process is not completed within 60 days
28 after the filing of the claim dispute with the health
29 maintenance organization, the provider may file a claim
30 dispute with a resolution organization.
31 Section 10. This act shall take effect July 1, 2001.
15
CODING: Words stricken are deletions; words underlined are additions.
Florida House of Representatives - 2001 HB 1235
751-103-01
1 *****************************************
2 SENATE SUMMARY
3 Revises various provisions governing the payment of
claims by health insurers and health maintenance
4 organizations. Revises requirements for paying benefits
under multiple health insurance policies. Defines the
5 term "clean claim." Requires that a claim be paid within
a specified period. Requires payment of interest on
6 overdue payments. Defines the term "emergency medical
condition." Prohibits certain limits on the provision of
7 emergency services. Revises requirements for health
maintenance organization with respect to treatment
8 authorizations. See bill for details.
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
16
CODING: Words stricken are deletions; words underlined are additions.