Florida Senate - 2024                                    SB 1574
       
       
        
       By Senator Jones
       
       
       
       
       
       34-01577-24                                           20241574__
    1                        A bill to be entitled                      
    2         An act relating to health care services; amending s.
    3         627.42392, F.S.; defining terms; revising the
    4         definitions of the terms “health insurer” as
    5         “utilization review entity”; requiring utilization
    6         review entities to establish and offer a prior
    7         authorization process for accepting electronic prior
    8         authorization requests by a specified date; specifying
    9         a requirement for the process; specifying additional
   10         requirements and procedures for, and restrictions and
   11         limitations on, utilization review entities relating
   12         to prior authorization for covered health care
   13         benefits; defining the term “medications for opioid
   14         use disorder”; providing construction; creating s.
   15         627.4262, F.S.; defining terms; prohibiting payment
   16         adjudicators from downcoding health care services
   17         under certain circumstances; requiring payment
   18         adjudicators to provide certain information prior to
   19         making their initial payment or notice of denial of
   20         payment; prohibiting downcoding by payment
   21         adjudicators for certain orders; providing that a
   22         payment adjudicator is solely responsible for certain
   23         violations of law; requiring payment adjudicators to
   24         maintain downcoding policies on their websites;
   25         specifying the requirements of such policies;
   26         providing that payment adjudicators are responsible
   27         for compliance with certain provisions; requiring
   28         payment adjudicators to develop certain internal
   29         procedures; authorizing the Office of Insurance
   30         Regulation to investigate and take appropriate actions
   31         under certain circumstances; providing severability;
   32         authorizing a provider to bring a private cause of
   33         action under certain circumstances; amending s.
   34         627.6131, F.S.; revising the requirements of insurer
   35         contracts; revising the definition of the term
   36         “claim”; defining terms; revising the requirements for
   37         health insurers submitting claims electronically and
   38         nonelectronically; making technical changes; deleting
   39         the prohibition against waiving, voiding, or
   40         nullifying certain provisions by contract; prohibiting
   41         a health insurer from retrospectively denying a claim
   42         under certain circumstances; revising procedures for
   43         investigation of claims of improper billing; providing
   44         construction; prohibiting health care insurers from
   45         requesting certain information or resubmission of
   46         claims under certain circumstances; prohibiting an
   47         insurer from requiring information from a provider
   48         before the provision of emergency services and care;
   49         providing an effective date.
   50          
   51  Be It Enacted by the Legislature of the State of Florida:
   52  
   53         Section 1. Section 627.42392, Florida Statutes, is amended
   54  to read:
   55         627.42392 Prior authorization.—
   56         (1) As used in this section, the term:
   57         (a)“Adverse determination” means a decision by a health
   58  insurer or utilization review entity to deny, reduce, or
   59  terminate health care services furnished or proposed to be
   60  furnished to an insured. The term does not include a decision to
   61  deny, reduce, or terminate services that were determined to be
   62  duplicate bills or that are confirmed with the provider to have
   63  been billed in error.
   64         (b)“Electronic prior authorization process” does not
   65  include transmissions through a facsimile machine.
   66         (c)“Emergency health care services” has the same meaning
   67  as “emergency services and care” as defined in s. 395.002.
   68         (d)“Prior authorization” means the process by which health
   69  insurers, third-party payors, or utilization review entities
   70  determine the medical necessity of nonemergency health care
   71  services before the rendering of such services by the provider.
   72  Such prior authorization is authorized by the applicable
   73  agreement with the health care provider or such prior
   74  authorization is otherwise obtained by a provider that does not
   75  have such an agreement. The term also includes a health
   76  insurer’s or utilization review entity’s requirement, if such
   77  requirement is permitted by the applicable agreement with a
   78  health care provider or otherwise permitted by a health care
   79  provider that does not have such an agreement, that a patient or
   80  health care provider notify the health insurer or utilization
   81  review entity before the provision of a nonemergency health care
   82  service.
   83         (e)“Urgent health care service” means a health care
   84  service to treat a medical condition that, if the timeframe for
   85  making a nonexpedited prior authorization were to be applied,
   86  could, in the opinion of a physician with knowledge of the
   87  patient’s medical condition:
   88         1.Seriously jeopardize the life or health of the patient
   89  or the ability of the patient to regain maximum function; or
   90         2.Subject the patient to severe pain that cannot be
   91  adequately managed without the care, treatment, or prescription
   92  drug that is the subject of the prior authorization request.
   93         (f)“Utilization review activity” means any action taken
   94  prospective to, concurrent with, or retrospective to the
   95  provision of nonemergency health care services to determine
   96  whether a claim is paid or is subject to an adverse
   97  determination. Utilization review activity is not allowed to the
   98  extent restricted or prohibited by an agreement with a health
   99  care provider or, other than to verify a presenting emergency
  100  medical condition, for emergency health care services. For
  101  purposes of this paragraph, the term “a presenting emergency
  102  medical condition” means a medical condition manifesting itself
  103  by acute symptoms of sufficient severity, including severe pain,
  104  such that a prudent layperson who possesses an average knowledge
  105  of health and medicine could reasonably expect the absence of
  106  immediate medical attention to result in a condition or
  107  situation described in s. 395.002(8).
  108         (g)“Utilization review entity” “health insurer” means an
  109  authorized insurer offering health insurance as defined in s.
  110  624.603, a managed care plan as defined in s. 409.962(10), or a
  111  health maintenance organization as defined in s. 641.19(12), a
  112  pharmacy benefit manager as defined in s. 624.490, or any other
  113  individual or entity that provides, offers to provide, or
  114  administers payment for hospital services, outpatient services,
  115  medical services, prescription drugs, or other health care
  116  services to a person treated by a health care professional or
  117  facility in this state under a policy, plan, or contract.
  118         (2) Beginning January 1, 2025, a utilization review entity
  119  shall establish and offer a secure, interactive, online,
  120  electronic prior authorization process for accepting electronic
  121  prior authorization requests. The process must allow a person
  122  seeking prior authorization the ability to upload documentation
  123  if such documentation is required by the utilization review
  124  entity to make a determination on the prior authorization
  125  request.
  126         (3) Notwithstanding any other provision of law, effective
  127  January 1, 2017, or 6 six (6) months after the effective date of
  128  the rule adopting the prior authorization form, whichever is
  129  later, a utilization review entity that health insurer, or a
  130  pharmacy benefits manager on behalf of the health insurer, which
  131  does not provide an electronic prior authorization process for
  132  use by its contracted providers, shall use only use the prior
  133  authorization form that has been approved by the Financial
  134  Services commission for granting a prior authorization for a
  135  medical procedure, course of treatment, or prescription drug
  136  benefit. Such form may not exceed two pages in length, excluding
  137  any instructions or guiding documentation, and must include all
  138  clinical documentation necessary for the utilization review
  139  entity health insurer to make a decision. At a minimum, the form
  140  must include:
  141         (a)(1) Sufficient patient information to identify the
  142  member, date of birth, full name, and health plan ID number;
  143         (b)(2)The provider’s provider name, address, and phone
  144  number;
  145         (c)(3) The medical procedure, course of treatment, or
  146  prescription drug benefit being requested, including the medical
  147  reason therefor, and all services tried and failed;
  148         (d)(4) Any laboratory documentation required; and
  149         (e)(5) An attestation that all information provided is true
  150  and accurate.
  151         (4)(3) The Financial Services commission, in consultation
  152  with the Agency for Health Care Administration, shall adopt by
  153  rule guidelines for all prior authorization forms which ensure
  154  the general uniformity of such forms.
  155         (5)(4) Electronic prior authorization approvals do not
  156  preclude benefit verification or medical review by the
  157  utilization review entity insurer under either the medical or
  158  pharmacy benefits.
  159         (6)A utilization review entity’s prior authorization
  160  process may not require information that is not needed to make a
  161  determination or facilitate a determination of medical necessity
  162  of the requested medical procedure, course of treatment, or
  163  prescription drug benefit.
  164         (7)A utilization review entity shall disclose all of its
  165  prior authorization requirements and restrictions, including any
  166  written clinical criteria, in a publicly accessible manner on
  167  its website. Such information must be explained in detail and in
  168  clear and ordinary terms.
  169         (8)A utilization review entity may not implement any new
  170  requirement or restriction or make changes to existing
  171  requirements for or restrictions on obtaining prior
  172  authorization unless both of the following conditions are met:
  173         (a)The changes have been available on a publicly
  174  accessible website for at least 60 days before they are
  175  implemented.
  176         (b)Insureds and health care providers affected by the new
  177  requirements and restrictions or by the changes to the
  178  requirements and restrictions are provided with a written notice
  179  of the changes at least 60 days before they are implemented.
  180  Such notice must be delivered electronically or by other means
  181  as agreed to by the insured or the health care provider.
  182         (9)A utilization review entity shall make available on its
  183  website, in a readily accessible format, data regarding prior
  184  authorization approvals and denials, which must include all of
  185  the following:
  186         (a)All items and services requiring prior authorization.
  187         (b)The percentage, in aggregate, of prior authorization
  188  requests approved.
  189         (c)The percentage, in aggregate, of prior authorization
  190  requests denied.
  191         (d)The percentage of prior authorization requests approved
  192  after appeal.
  193         (e)The percentage of prior authorization requests in which
  194  the timeframe for review was extended and the prior
  195  authorization request was approved.
  196         (f)The percentage of expedited prior authorization
  197  requests approved.
  198         (g)The average and median time between submission of a
  199  request for prior authorization and a determination of the
  200  outcome.
  201         (h)The average and median time between submission of a
  202  request for an expedited prior authorization and a determination
  203  of the outcome.
  204  
  205  This subsection does not apply to the expansion of health care
  206  services coverage.
  207         (10)A utilization review entity shall ensure that all
  208  adverse determinations are made by a physician licensed pursuant
  209  to chapter 458 or chapter 459. All of the following requirements
  210  apply to such physicians:
  211         (a)The physician must possess a current and valid
  212  nonrestricted license to practice medicine in this state.
  213         (b)The physician must be of the same specialty as the
  214  physician who typically manages the medical condition or disease
  215  or who provides the health care service that is the subject of
  216  the request.
  217         (c)The physician must have experience treating patients
  218  with the medical condition or disease for which the health care
  219  service is being requested.
  220         (11)Notice of an adverse determination must be provided by
  221  e-mail to the health care provider that initiated the prior
  222  authorization. The notice must include all of the following:
  223         (a)The name, title, e-mail address, and telephone number
  224  of the physician responsible for making the adverse
  225  determination.
  226         (b)Any written clinical criteria and any internal rule,
  227  guideline, or protocol that the utilization review entity relied
  228  upon in making the adverse determination, and how such rule,
  229  guideline, or protocol applies to the insured’s specific medical
  230  circumstance.
  231         (c)Information for the insured and the insured’s health
  232  care provider which describes the procedure through which the
  233  insured or health care provider may request a copy of any report
  234  developed by the health care provider performing the review that
  235  led to the adverse determination.
  236         (d)An explanation to the insured and the insured’s health
  237  care provider of the appeals process for an adverse
  238  determination.
  239         (12)If a utilization review entity requires prior
  240  authorization of a nonemergency health care service, the
  241  utilization review entity must make an authorization or adverse
  242  determination and notify the insured and the insured’s provider
  243  of such service of the decision within 2 business days after
  244  obtaining all necessary information to make the authorization or
  245  adverse determination. For purposes of this subsection,
  246  necessary information includes the results of any face-to-face
  247  clinical evaluation or second opinion that may be required.
  248         (13)A utilization review entity shall render an expedited
  249  authorization or adverse determination concerning an emergency
  250  health care service and notify the insured and the insured’s
  251  provider of such service of the expedited prior authorization or
  252  adverse determination no later than 1 business day after
  253  receiving all information needed to complete the review of the
  254  requested urgent health care service.
  255         (14)A utilization review entity may not require prior
  256  authorization for prehospital transportation or for provision of
  257  an emergency health care service. A utilization review entity
  258  may not conduct any utilization review activity, nor render any
  259  adverse determinations, to the extent restricted or prohibited
  260  by an agreement with a health care provider. A utilization
  261  review entity may not perform any utilization review activity,
  262  nor render any adverse determinations, with respect to emergency
  263  health care services beyond verification of the presenting
  264  emergency medical condition.
  265         (15)A utilization review entity may not require prior
  266  authorization for the provision of medications for opioid use
  267  disorder. As used in this subsection, the term “medications for
  268  opioid use disorder” means the use of medications approved by
  269  the United States Food and Drug Administration (FDA), commonly
  270  in combination with counseling and behavioral therapies, to
  271  provide a comprehensive approach to the treatment of opioid use
  272  disorder. Such FDA-approved medications used to treat opioid
  273  addiction include, but are not limited to, methadone;
  274  buprenorphine, alone or in combination with naloxone; and
  275  extended-release injectable naltrexone. Such types of behavioral
  276  therapies include, but are not limited to, individual therapy,
  277  group counseling, family therapy, motivational incentives, and
  278  other modalities.
  279         (16)A utilization review entity may not revoke, limit,
  280  condition, or restrict a prior authorization if care is provided
  281  within 45 business days after the date the health care provider
  282  received the prior authorization. A utilization review entity
  283  shall pay the health care provider at the contracted payment
  284  rate for a health care service provided by the health care
  285  provider under a prior authorization unless any of the following
  286  is true:
  287         (a)The health care provider knowingly and materially
  288  misrepresented the health care service in the prior
  289  authorization request with the specific intent to deceive and
  290  obtain an unlawful payment from the utilization review entity.
  291         (b)The health care service was no longer a covered benefit
  292  on the day it was provided, and the utilization review entity
  293  notified the health care provider in writing of this fact before
  294  the health care service was provided.
  295         (c)The authorized service was never performed.
  296         (d)The insured was no longer eligible for health care
  297  coverage on the day the care was provided, and the utilization
  298  review entity notified the health care provider in writing of
  299  this fact before the health care service was provided.
  300         (17)If a utilization review entity required a prior
  301  authorization for a health care service for the treatment of a
  302  chronic or long-term care condition, the prior authorization
  303  remains valid for the length of the treatment and the
  304  utilization review entity may not require the insured to obtain
  305  a prior authorization again for the health care service.
  306         (18)A utilization review entity may not impose an
  307  additional prior authorization requirement with respect to a
  308  surgical or otherwise invasive procedure, or any item furnished
  309  as part of such a procedure, if the procedure or item is
  310  furnished during the perioperative period of another procedure
  311  for which prior authorization was granted by the utilization
  312  review entity.
  313         (19)Any change in coverage or approval criteria for a
  314  previously authorized health care service may not affect an
  315  insured who received prior authorization before the effective
  316  date of the change for the remainder of the insured’s plan year.
  317         (20)A utilization review entity shall continue to honor a
  318  prior authorization it has granted to an insured when the
  319  insured changes coverage under the same insurance company.
  320         (21)Any health care services subject to review are
  321  automatically deemed authorized by the utilization review entity
  322  if it fails to comply with the deadlines and other requirements
  323  specified in this section.
  324         (22)Except as otherwise provided in subsection (16), a
  325  prior authorization constitutes a conclusive determination of
  326  the medical necessity of the authorized health care service and
  327  an irrevocable obligation to pay for such authorized health care
  328  service.
  329         (23) The requirements of this section cannot be waived by
  330  contract. Any contractual arrangement or action taken in
  331  conflict with this section, or which purports to waive any
  332  requirement of this section, is void.
  333         (24)This section does not prohibit an agreement with a
  334  health care provider to restrict, limit, prohibit, or substitute
  335  utilization review activity or prior authorization.
  336         Section 2. Section 627.4262, Florida Statutes, is created
  337  to read:
  338         627.4262 Payment adjudication.—
  339         (1)For the purposes of this section, the term:
  340         (a)“Downcode” or “downcoding” means the alteration by a
  341  payment adjudicator of the service code to another service code
  342  or the alteration, addition, or removal by a payment adjudicator
  343  of a modifier, when the changed code or modifier is associated
  344  with a lower payment amount than the service code or modifier
  345  billed by the provider or facility.
  346         (b)“Health plan” means any entity that offers health
  347  insurance coverage, whether through a fully insured plan or a
  348  self-insured plan or fund, including an authorized insurer
  349  offering health insurance as defined in s. 624.603, any entity
  350  that offers a self-insured fund as described in s. 624.462, or
  351  group self-insurance funds as described in 624.4621, a health
  352  insurer subject to chapter 627, a managed care plan as defined
  353  in s. 409.962, or a health maintenance organization as defined
  354  in s. 641.19.
  355         (c)“Medical record” means the comprehensive collection of
  356  documentation, including clinical notes, diagnostic reports, and
  357  other relevant information, which supports the health care
  358  services provided.
  359         (d)“Participation agreement” means a written contract or
  360  agreement between a health plan and a provider which outlines
  361  the terms and conditions of participation, reimbursement rates,
  362  and other relevant details.
  363         (e)“Payment adjudicator” means a health plan or any entity
  364  that provides, offers to provide, or administers payment on
  365  behalf of a health plan, as well any pharmacy benefit manager as
  366  defined in s. 626.88, and any other individual or entity that
  367  provides, offers to provide, or administers payment for hospital
  368  services, outpatient services, medical services, prescription
  369  drugs, or other health care services to a person treated by a
  370  health care professional or facility in this state under a
  371  policy, plan, or contract.
  372         (f)“Provider” includes any health care professional,
  373  facility, or entity that submits claims for reimbursement for
  374  covered health care services provided to individuals covered
  375  under a health plan.
  376         (2)(a)Payment adjudicators are prohibited from downcoding
  377  a health care service billed by, or on behalf of, a provider, if
  378  the health care service was ordered by a provider in-network
  379  with the applicable health plan, unless such downcoding is
  380  otherwise expressly allowed under the participation agreement
  381  between the health plan and such provider.
  382         (b)If downcoding is expressly allowed under the
  383  participation agreement, the payment adjudicator must first
  384  conduct a review of the associated medical record to ensure the
  385  accuracy of the coding change, and then provide the following
  386  information to the provider before making its initial payment or
  387  notice of denial of payment:
  388         1.A statement indicating that the service code or modifier
  389  billed by the provider or facility is going to be downcoded.
  390         2.An explanation detailing the reasons for downcoding the
  391  claim. This explanation must include a clear description of the
  392  service codes or modifiers that were altered, added, or removed,
  393  if applicable.
  394         3.The payment amount that the payment adjudicator would
  395  otherwise make if the service code or modifier was not
  396  downcoded.
  397         4.A statement that the provider may contest the downcoding
  398  of the applicable service code or modifier by filing a
  399  contestation with the payment adjudicator with respect to the
  400  downcoding within 15 days after receipt of the statements
  401  required under this paragraph.
  402         5.A statement that, by contesting the downcoding of the
  403  applicable service code or modifier, the provider does not waive
  404  any of its legal rights to pursue claims against the health plan
  405  or payment adjudicator.
  406         (c)A payment adjudicator may not downcode a service code
  407  or modifier for services provided pursuant to orders issued by a
  408  licensed nurse.
  409         (d)Notwithstanding this section, a payment adjudicator
  410  that downcodes a service code or modifier, regardless of whether
  411  such downcoding is contested by the provider, is solely
  412  responsible for any violations of law associated with such
  413  downcoding.
  414         (3)(a)Payment adjudicators shall maintain clear and
  415  accessible downcoding policies on their official websites. These
  416  policies must include all of the following:
  417         1.An overview of the circumstances under which downcoding
  418  may occur.
  419         2.The process and criteria used for conducting reviews of
  420  downcoded claims, including the role of medical record review.
  421         3.Information about the internal mechanisms for ensuring
  422  consistency and accuracy in downcoding practices.
  423         4.Information regarding the processes for contesting the
  424  downcode of a service code with the payment adjudicator.
  425         (b)Health plans shall ensure that their downcoding
  426  policies are updated, as needed, to reflect any changes in
  427  regulations, industry standards, or internal procedures.
  428         (4)(a)Payment adjudicators are responsible for ensuring
  429  compliance with this section and shall develop internal
  430  procedures to implement and adhere to the requirements thereof.
  431         (b)The office may investigate and take appropriate actions
  432  in cases of noncompliance with this section.
  433         (5)If any provision of this section or its application to
  434  any person or circumstances is held invalid, the invalidity does
  435  not affect other provisions or applications of this section
  436  which can be given effect without the invalid provision or
  437  application, and to this end the provisions of this section are
  438  severable.
  439         (6)A provider may bring a private cause of action against
  440  the payment adjudicator for a violation of this section.
  441         Section 3. Present subsections (18) and (19) of section
  442  627.6131, Florida Statutes, are redesignated as subsections (22)
  443  and (23), respectively, new subsections (18) and (19) and
  444  subsections (20) and (21) are added to that section, and
  445  subsections (1) and (2), paragraphs (a) and (c) of subsection
  446  (4), paragraphs (a) and (c) of subsection (5), and subsections
  447  (6), (10), (11), and (13) of that section are amended, to read:
  448         627.6131 Payment of claims.—
  449         (1) The contract must shall include the following
  450  provision: “Time of Payment of Claims: After receiving written
  451  proof of loss, the insurer will pay monthly all claims benefits
  452  then due for ...(type of benefit).... Claims Benefits for any
  453  other loss covered by this policy will be paid as soon as the
  454  insurer receives proper written proof.”
  455         (2) As used in this section, the term:
  456         (a) “Claim,” for a noninstitutional provider, means a
  457  paper, Centers for Medicare and Medicaid Services (CMS) 1500
  458  form, or its successor, or electronic billing instrument
  459  submitted to the insurer’s designated location which that
  460  consists of the ANSI ASC X12N 837P standard HCFA 1500 data set,
  461  or its successor, which that has all mandatory entries for a
  462  physician licensed under chapter 458, chapter 459, chapter 460,
  463  chapter 461, or chapter 463, or psychologists licensed under
  464  chapter 490 or any appropriate billing instrument that has all
  465  mandatory entries for any other noninstitutional provider. For
  466  institutional providers, the term “claim” means a paper or
  467  electronic billing instrument submitted to the insurer’s
  468  designated location which that consists of the ANSI ASC X12N
  469  837P standard UB-92 data set, or its successor, with entries
  470  stated as mandatory by the National Uniform Billing Committee.
  471         (b)“Clean claim” means a completed form or completed
  472  electronic billing instrument referenced in paragraph (a) which
  473  contains all of the following information:
  474         1.All information required under the applicable form or
  475  electronic billing instrument.
  476         2.Information reasonably required by the insurer to
  477  substantiate the claim, which, except for emergency services and
  478  care as defined in s. 641.47, is submitted in advance of the
  479  provision of service.
  480         (c)“Insured ineligibility” means a circumstance in which
  481  an insured is no longer enrolled in the health plan at the time
  482  of receiving the applicable service.
  483         (d)“Overpayment” means a payment that is billed in error,
  484  a duplicate claim, or a payment for a service rendered to a
  485  patient for a service because of insured ineligibility.
  486         (4) For all electronically submitted claims, a health
  487  insurer shall:
  488         (a) Within 24 hours after the beginning of the next
  489  business day after receipt of the claim, provide, to the
  490  electronic source submitting the claim, an electronic
  491  acknowledgment of the receipt of the claim along with its
  492  position as to whether the claim is a clean claim or whether the
  493  claim is missing any information required under the applicable
  494  electronic billing instrument provided in paragraph (2)(a) or
  495  that was reasonably required by the insurer in advance of the
  496  provision of service, other than emergency services and care as
  497  defined in s. 641.47, to substantiate the claim to the
  498  electronic source submitting the claim.
  499         (c)1. Notification of the health insurer’s determination of
  500  a contested claim must be accompanied by an itemized list of any
  501  additional information required under the applicable billing
  502  instrument specified in paragraph (2)(a) or which was reasonably
  503  required by the insurer and the health insurer asserts is still
  504  missing as of the date of such service, other than for emergency
  505  services and care as defined in s. 641.47 or documents the
  506  insurer can reasonably determine are necessary to process the
  507  claim.
  508         2. A provider must submit the additional information or
  509  documentation, as specified on the itemized list, within 35 days
  510  after receipt of the notification unless within such 35-day
  511  period the provider notifies the insurer of its position that a
  512  clean claim has been submitted. Additional information is
  513  considered submitted on the date it is electronically
  514  transferred or mailed. The health insurer may not request
  515  duplicate documents.
  516         (5) For all nonelectronically submitted claims, a health
  517  insurer shall:
  518         (a) Effective November 1, 2003, Provide to the provider
  519  submitting the claim an acknowledgment of receipt of the claim
  520  along with its position as to whether the claim is a clean claim
  521  or whether the claim is missing any information required under
  522  the applicable paper billing form described in paragraph (2)(a)
  523  which was reasonably required by the insurer to substantiate the
  524  claim in advance of the provision of service, other than for
  525  emergency services and care as defined in s. 641.47, within 15
  526  days after receipt of the claim to the provider or provide a
  527  provider within 15 days after receipt with electronic access to
  528  the status of a submitted claim.
  529         (c)1. Notification of the health insurer’s determination of
  530  a contested claim must be accompanied by an itemized list of any
  531  additional information required under the applicable billing
  532  instrument described in paragraph (2)(a) or which was reasonably
  533  required by the insurer to substantiate the claim in advance of
  534  the provision of service, other than for emergency services and
  535  care as defined in s. 641.47, which the health insurer asserts
  536  is still missing as of the date of such service or documents the
  537  insurer can reasonably determine are necessary to process the
  538  claim.
  539         2. A provider must submit the additional information or
  540  documentation, as specified on the itemized list, within 35 days
  541  after receipt of the notification unless, within such 35-day
  542  period, the provider notifies the insurer of its position that a
  543  clean claim has been submitted. Additional Information is
  544  considered submitted on the date it is electronically
  545  transferred or mailed. The health insurer may not request
  546  duplicate documents.
  547         (6) If a health insurer determines that it has made an
  548  overpayment to a provider for services rendered to an insured,
  549  the health insurer must make a claim for such overpayment to the
  550  provider’s designated location. A health insurer that makes a
  551  claim for overpayment to a provider under this section shall
  552  give the provider a written or electronic statement specifying
  553  the basis for the retrospective retroactive denial or payment
  554  adjustment. The insurer must identify the claim or claims, or
  555  overpayment claim portion thereof, for which a claim for
  556  overpayment is submitted.
  557         (a) If an overpayment determination is the result of
  558  retrospective retroactive review or retrospective audit of
  559  coverage decisions or payment levels not related to fraud, a
  560  health insurer must shall adhere to all of the following
  561  procedures:
  562         1. All claims for overpayment must be submitted to a
  563  provider within 30 months after the health insurer’s payment of
  564  the claim. A provider must pay, deny, or contest the health
  565  insurer’s claim for overpayment within 40 days after the receipt
  566  of the claim. All contested claims for overpayment must be paid
  567  or denied within 120 days after receipt of the claim. Failure to
  568  pay or deny overpayment and claim within 140 days after receipt
  569  creates an uncontestable obligation to pay the claim.
  570         2. A provider that denies or contests a health insurer’s
  571  claim for overpayment or any portion of a claim shall notify the
  572  health insurer, in writing, within 35 days after the provider
  573  receives the claim that the claim for overpayment is contested
  574  or denied. The notice that the claim for overpayment is denied
  575  or contested must identify the contested portion of the claim
  576  and the specific reason for contesting or denying the claim and,
  577  if contested, must include a request for additional information.
  578  If the health insurer submits additional information, the health
  579  insurer must, within 35 days after receipt of the request, mail
  580  or electronically transfer the information to the provider. The
  581  provider shall pay or deny the claim for overpayment within 45
  582  days after receipt of the information. The notice is considered
  583  made on the date the notice is mailed or electronically
  584  transferred by the provider.
  585         3. The health insurer may not reduce payment to the
  586  provider for other services unless the provider agrees to the
  587  reduction in writing or fails to respond to the health insurer’s
  588  overpayment claim as required by this paragraph.
  589         4. Payment of an overpayment claim is considered made on
  590  the date the payment was mailed or electronically transferred.
  591  An overdue payment of a claim bears simple interest at the rate
  592  of 12 percent per year. Interest on an overdue payment for a
  593  claim for an overpayment begins to accrue when the claim should
  594  have been paid, denied, or contested.
  595         (b) A claim for overpayment shall not be permitted beyond
  596  30 months after the health insurer’s payment of a claim, except
  597  that claims for overpayment may be sought beyond that time from
  598  providers convicted of fraud pursuant to s. 817.234.
  599         (10)The provisions of this section may not be waived,
  600  voided, or nullified by contract.
  601         (10)(11) A health insurer may not retrospectively
  602  retroactively deny a claim because of insured ineligibility more
  603  than 90 days 1 year after the date of payment of the claim.
  604         (12)(13) Upon written notification by an insured, an
  605  insurer shall investigate any claim of improper billing of the
  606  insured by a physician, hospital, or other health care provider
  607  for a health care service alleged not to have been received. The
  608  insurer shall determine if the insured received such service was
  609  properly billed for only those procedures and services that the
  610  insured actually received. If the insurer determines that the
  611  insured did not receive the service has been improperly billed,
  612  the insurer must shall notify the insured and the provider of
  613  its findings and shall reduce the amount of payment to the
  614  provider by the amount charged for the service that was not
  615  received determined to be improperly billed. If a reduction is
  616  made due to such notification by the insured, the insurer shall
  617  pay to the insured 20 percent of the amount of the reduction up
  618  to $500.
  619         (18)This section may not be interpreted to limit,
  620  restrict, or negatively impact any legal claim by a provider or
  621  insurer for breach of contract, statutory or regulatory
  622  violation, or under a common law cause of action, or shorten or
  623  otherwise negatively impact the statute of limitations timeframe
  624  for bringing any such legal claim.
  625         (19)A health insurer may not request information from a
  626  contracted or noncontracted provider which does not apply to the
  627  medical condition at issue for the purposes of making a
  628  determination of a clean claim.
  629         (20)A health insurer may not request a contracted or
  630  noncontracted provider to resubmit claim information that the
  631  contracted or noncontracted provider can document it has already
  632  provided to the health insurer.
  633         (21)Notwithstanding any law to the contrary, an insurer
  634  may not require any information from a provider before the
  635  provision of emergency services and care as defined in s. 641.47
  636  as a condition of payment of a claim, as a basis for denying or
  637  reducing payment of a claim, or in contesting whether the claim
  638  is a clean claim.
  639         Section 4. This act shall take effect July 1, 2024.