The Florida Senate

408.7057  Statewide provider and managed care organization claim dispute resolution program.--

(1)  As used in this section, the term:

(a)  "Managed care organization" means a health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized under s. 409.912, or an exclusive provider organization certified under s. 627.6472.

(b)  "Resolution organization" means a qualified independent third-party claim-dispute-resolution entity selected by and contracted with the Agency for Health Care Administration.

(2)(a)  The Agency for Health Care Administration shall establish a program by January 1, 2001, to provide assistance to contracted and noncontracted providers and managed care organizations for resolution of claim disputes that are not resolved by the provider and the managed care organization. The agency shall contract with a resolution organization to timely review and consider claim disputes submitted by providers and managed care organizations and recommend to the agency an appropriate resolution of those disputes. The agency shall establish by rule jurisdictional amounts and methods of aggregation for claim disputes that may be considered by the resolution organization.

(b)  The resolution organization shall review claim disputes filed by contracted and noncontracted providers and managed care organizations unless the disputed claim:

1.  Is related to interest payment;

2.  Does not meet the jurisdictional amounts or the methods of aggregation established by agency rule, as provided in paragraph (a);

3.  Is part of an internal grievance in a Medicare managed care organization or a reconsideration appeal through the Medicare appeals process;

4.  Is related to a health plan that is not regulated by the state;

5.  Is part of a Medicaid fair hearing pursued under 42 C.F.R. ss. 431.220 et seq.;

6.  Is the basis for an action pending in state or federal court; or

7.  Is subject to a binding claim-dispute-resolution process provided by contract entered into prior to October 1, 2000, between the provider and the managed care organization.

(c)  Contracts entered into or renewed on or after October 1, 2000, may require exhaustion of an internal dispute-resolution process as a prerequisite to the submission of a claim by a provider or health maintenance organization to the resolution organization when the dispute-resolution program becomes effective.

(d)  A contracted or noncontracted provider or health maintenance organization may not file a claim dispute with the resolution organization more than 12 months after a final determination has been made on a claim by a health maintenance organization.

(3)  The agency shall adopt rules to establish a process to be used by the resolution organization in considering claim disputes submitted by a provider or managed care organization which must include the issuance by the resolution organization of a written recommendation, supported by findings of fact, to the agency within 60 days after receipt of the claim dispute submission.

(4)  Within 30 days after receipt of the recommendation of the resolution organization, the agency shall adopt the recommendation as a final order.

(5)  The entity that does not prevail in the agency's order must pay a review cost to the review organization, as determined by agency rule. Such rule must provide for an apportionment of the review fee in any case in which both parties prevail in part. If the nonprevailing party fails to pay the ordered review cost within 35 days after the agency's order, the nonpaying party is subject to a penalty of not more than $500 per day until the penalty is paid.

(6)  The Agency for Health Care Administration may adopt rules to administer this section.

History.--s. 8, ch. 2000-252.