S 1198

Florida Senate - 2026  SB 1198
By Senator Massullo
11-00318A-26  20261198__
1A bill to be entitled
2An act relating to health insurance claims; amending
3s. 408.7057, F.S.; defining the term “denied prior
4authorization request”; expanding the scope of the
5statewide provider and health plan claim dispute
6resolution program to include resolution of denied
7prior authorization requests; providing that
8participation in the program is mandatory and
9prohibiting providers and health plans from opting out
10of the claim dispute resolution process; revising
11circumstances under which a claim dispute is exempt
12from the program’s claim dispute resolution process;
13providing that respondents in claim disputes may not
14avoid imposition of a default by declining to
15participate in the claim dispute resolution process;
16providing for reimbursement of reasonable costs to
17providers if the health plan is determined to be the
18nonprevailing party in a claim dispute involving a
19denied prior authorization request; requiring the
20Agency for Health Care Administration to adopt certain
21rules; amending ss. 627.6131 and 641.315, F.S.;
22prohibiting contracts between certain physicians and
23health insurers and health maintenance organizations,
24respectively, from specifying credit card payments to
25physicians as the only acceptable method for payments;
26authorizing use of electronic funds transfers by
27health insurers and health maintenance organizations,
28respectively, for payments to physicians under certain
29circumstances; providing notification requirements;
30prohibiting health insurers and health maintenance
31organizations, respectively, from charging fees for
32automated clearinghouse transfers as claims payments
33to physicians; providing an exception; providing
34applicability; prohibiting health insurers and health
35maintenance organizations, respectively, from denying
36claims subsequently submitted by physicians for
37procedures that were included in prior authorizations;
38providing exceptions; providing applicability;
39amending ss. 409.967 and 627.64194, F.S.; conforming
40provisions to changes made by the act; providing an
41effective date.
42
43Be It Enacted by the Legislature of the State of Florida:
44
45Section 1. Section 408.7057, Florida Statutes, is amended
46to read:
47408.7057 Mandatory statewide provider and health plan claim
48dispute resolution program.—
49(1) As used in this section, the term:
50(a) “Agency” means the Agency for Health Care
51Administration.
52(b) “Denied prior authorization request” means, with
53respect to a request submitted by a provider for prior
54authorization of a health care service, supply, or medication, a
55health plan has made a determination that the request is wholly
56or partially disapproved, has not been acted upon within the
57time limits established by law or contract, or is approved
58subject to materially restrictive conditions that prevent the
59service, supply, or medication from being furnished as
60clinically indicated.
61(c) “Health plan” means a health maintenance organization
62or a prepaid health clinic certified under chapter 641, a
63prepaid health plan authorized under s. 409.912, an exclusive
64provider organization certified under s. 627.6472, or a major
65medical expense health insurance policy, as defined in s.
66627.643(2)(e), offered by a group or an individual health
67insurer licensed pursuant to chapter 624, including a preferred
68provider organization under s. 627.6471.
69(d)[(c)] “Resolution organization” means a qualified
70independent third-party claim-dispute-resolution entity selected
71by and contracted with the Agency for Health Care
72Administration.
73(2)(a) The agency shall establish a program to provide
74assistance to contracted and noncontracted providers and health
75plans for resolution of claim disputes and denied prior
76authorization requests that are not resolved by the provider and
77the health plan. The agency shall contract with a resolution
78organization to timely review and consider claim disputes and
79denied prior authorization requests submitted by providers and
80health plans and recommend to the agency an appropriate
81resolution of those disputes. The agency shall establish by rule
82jurisdictional amounts and methods of aggregation for claim
83disputes and denied prior authorization requests that may be
84considered by the resolution organization.
85(b) Participation in the claim dispute resolution program
86is mandatory, and a provider or health plan may not opt out of
87the program’s claim dispute resolution process. The resolution
88organization shall review all claim disputes filed by contracted
89and noncontracted providers and health plans unless the disputed
90claim:
911. Is related to interest payment;
922. Does not meet the jurisdictional amounts or the methods
93of aggregation established by agency rule, as provided in
94paragraph (a);
953. Is part of an internal grievance in a Medicare managed
96care organization or a reconsideration appeal through the
97Medicare appeals process;
984. Is related to a health plan that is not regulated by the
99state;
1005. Is part of a Medicaid fair hearing pursued under 42
101C.F.R. ss. 431.220 et seq.;
1026. Is specifically the subject of an existing lawsuit filed
103[basis for an action pending] in state or federal court before the
104submission of the claim to the resolution organization; or
1057. Is subject to a binding claim-dispute-resolution process
106provided by contract entered into before [prior to] October 1,
1072000, between the provider and the managed care organization.
108(c) Contracts entered into or renewed on or after October
1091, 2000, may require exhaustion of an internal dispute
110resolution process as a prerequisite to the submission of a
111claim by a provider or a health plan to the resolution
112organization.
113(d) A contracted or noncontracted provider or health plan
114may not file a claim dispute with the resolution organization
115more than 12 months after a final determination has been made on
116a claim by a health plan or provider.
117(e) The resolution organization shall require the health
118plan or provider submitting the claim dispute to submit any
119supporting documentation to the resolution organization within
12015 days after receipt by the health plan or provider of a
121request from the resolution organization for documentation in
122support of the claim dispute. The resolution organization may
123extend the time if appropriate. Failure to submit the supporting
124documentation within such time period shall result in the
125dismissal of the submitted claim dispute.
126(f) The resolution organization shall require the
127respondent in the claim dispute to submit all documentation in
128support of its position within 15 days after receiving a request
129from the resolution organization for supporting documentation.
130The resolution organization may extend the time if appropriate.
131Failure to submit the supporting documentation within such time
132period shall result in a default against the health plan or
133provider. A respondent may not avoid a default by declining to
134participate in the claim dispute resolution process set forth in
135this section. In the event of such a default, the resolution
136organization shall issue its written recommendation to the
137agency that a default be entered against the defaulting entity.
138The written recommendation shall include a recommendation to the
139agency that the defaulting entity shall pay the entity
140submitting the claim dispute the full amount of the claim
141dispute, plus all accrued interest, and shall be considered a
142nonprevailing party for the purposes of this section.
143(g)1. If on an ongoing basis during the preceding 12
144months, the agency has reason to believe that a pattern of
145noncompliance with s. 627.6131 and s. 641.3155 exists on the
146part of a particular health plan or provider, the agency shall
147evaluate the information contained in these cases to determine
148whether the information evidences a pattern and report its
149findings, together with substantiating evidence, to the
150appropriate licensure or certification entity for the health
151plan or provider.
1522. In addition, the agency shall prepare a report to the
153Governor and the Legislature by February 1 of each year,
154enumerating: claims dismissed; defaults issued; and failures to
155comply with agency final orders issued under this section.
156(h) Either the contracted or noncontracted provider or the
157health plan may make an offer to settle the claim dispute when
158it submits a request for a claim dispute and supporting
159documentation. The offer to settle the claim dispute must state
160its total amount, and the party to whom it is directed has 15
161days to accept the offer once it is received. If the party
162receiving the offer does not accept the offer and the final
163order amount is more than 90 percent or less than 110 percent of
164the offer amount, the party receiving the offer must pay the
165final order amount to the offering party and is deemed a
166nonprevailing party for purposes of this section. The amount of
167an offer made by a contracted or noncontracted provider to
168settle an alleged underpayment by the health plan must be
169greater than 110 percent of the reimbursement amount the
170provider received. The amount of an offer made by a health plan
171to settle an alleged overpayment to the provider must be less
172than 90 percent of the alleged overpayment amount by the health
173plan. Both parties may agree to settle the disputed claim at any
174time, for any amount, regardless of whether an offer to settle
175was made or rejected.
176(3) The agency shall adopt rules to establish a process to
177be used by the resolution organization in considering claim
178disputes submitted by a provider or health plan which must
179include:
180(a) That the resolution organization review and consider
181all documentation submitted by both the health plan and the
182provider;
183(b) That the resolution organization’s recommendation make
184findings of fact;
185(c) That either party may request that the resolution
186organization conduct an evidentiary hearing in which both sides
187can present evidence and examine witnesses, and for which the
188cost of the hearing is equally shared by the parties;
189(d) That the resolution organization may not communicate ex
190parte with either the health plan or the provider during the
191dispute resolution;
192(e) That the resolution organization’s written
193recommendation, including findings of fact relating to the
194calculation under s. 641.513(5) for the recommended amount due
195for the disputed claim, include any evidence relied upon; and
196(f) That the resolution organization issue a written
197recommendation to the agency within 60 days after the requested
198information is received by the resolution organization within
199the timeframes specified by the resolution organization. In no
200event shall the review time exceed 90 days following receipt of
201the initial claim dispute submission by the resolution
202organization.
203(4) Within 30 days after receipt of the recommendation of
204the resolution organization, the agency shall adopt the
205recommendation as a final order. The final order is subject to
206judicial review pursuant to s. 120.68.
207(5) The agency shall notify within 7 days the appropriate
208licensure or certification entity whenever there is a violation
209of a final order issued by the agency pursuant to this section.
210(6) The entity that does not prevail in the agency’s order
211must pay a review cost to the review organization, as determined
212by agency rule. Such rule must provide for an apportionment of
213the review fee in any case in which both parties prevail in
214part. If the nonprevailing party fails to pay the ordered review
215cost within 35 days after the agency’s order, the nonpaying
216party is subject to a penalty of not more than $500 per day
217until the penalty is paid.
218(7) If a claim dispute under this section involves a denied
219prior authorization request and the health plan is determined to
220be the nonprevailing party, the health plan must reimburse the
221provider for the provider’s reasonable costs incurred in
222bringing the claim, including any filing fees and administrative
223costs assessed by the agency or its designee.The agency shall
224adopt rules to specify allowable costs and procedures for
225recovering such costs under this subsection.
226(8) The agency may adopt rules to administer this section.
227Section 2. Subsections (20) and (21) of section 627.6131,
228Florida Statutes, are amended to read:
229627.6131 Payment of claims.—
230(20)(a) A contract between a health insurer and a dentist
231licensed under chapter 466 or a physician licensed under chapter
232458 or chapter 459 for the provision of services to an insured
233may not specify credit card payment as the only acceptable
234method for payments from the health insurer to the dentist or
235physician.
236(b) When a health insurer employs the method of claims
237payment to a dentist or physician through electronic funds
238transfer, including, but not limited to, virtual credit card
239payment, the health insurer shall notify the dentist or
240physician as provided in this paragraph and obtain the dentist’s
241or physician’s consent before employing the electronic funds
242transfer. The dentist’s or physician’s consent described in this
243paragraph applies to the dentist’s or physician’s entire
244practice. For the purpose of this paragraph, the dentist’s or
245physician’s consent, which may be given through e-mail, must
246bear the signature of the dentist or physician. Such signature
247includes an electronic or digital signature if the form of
248signature is recognized as a valid signature under applicable
249federal law or state contract law or an act that demonstrates
250express consent, including, but not limited to, checking a box
251indicating consent. The health insurer or the dentist or
252physician may not require that a dentist’s or physician’s
253consent as described in this paragraph be made on a patient-by
254patient basis. The notification provided by the health insurer
255to the dentist or physician must include all of the following:
2561. The fees, if any, associated with the electronic funds
257transfer.
2582. The available methods of payment of claims by the health
259insurer, with clear instructions to the dentist or physician on
260how to select an alternative payment method.
261(c) A health insurer that pays a claim to a dentist or
262physician through automated clearinghouse transfer may not
263charge a fee solely to transmit the payment to the dentist or
264physician unless the dentist or physician has consented to the
265fee.
266(d) This subsection applies to all contracts:
2671.Between a health insurer and a dentist which are
268delivered, issued, or renewed on or after January 1, 2025.
2692.Between a health insurer and a physician which are
270delivered, issued, or renewed on or after January 1, 2027.
271(e) The office has all rights and powers to enforce this
272subsection as provided by s. 624.307.
273(f) The commission may adopt rules to implement this
274subsection.
275(21)(a) A health insurer may not deny any claim
276subsequently submitted by a dentist licensed under chapter 466
277or a physician licensed under chapter 458 or chapter 459 for
278procedures specifically included in a prior authorization unless
279at least one of the following circumstances applies for each
280procedure denied:
2811. Benefit limitations, such as annual maximums and
282frequency limitations not applicable at the time of the prior
283authorization, are reached subsequent to issuance of the prior
284authorization.
2852. The documentation provided by the person submitting the
286claim fails to support the claim as originally authorized.
2873. Subsequent to the issuance of the prior authorization,
288new procedures are provided to the patient or a change in the
289condition of the patient occurs such that the prior authorized
290procedure would no longer be considered medically necessary,
291based on the prevailing standard of care.
2924. Subsequent to the issuance of the prior authorization,
293new procedures are provided to the patient or a change in the
294patient’s condition occurs such that the prior authorized
295procedure would at that time have required disapproval pursuant
296to the terms and conditions for coverage under the patient’s
297plan in effect at the time the prior authorization was issued.
2985. The denial of the claim was due to one of the following:
299a. Another payor is responsible for payment.
300b. The dentist or physician has already been paid for the
301procedures identified in the claim.
302c. The claim was submitted fraudulently, or the prior
303authorization was based in whole or material part on erroneous
304information provided to the health insurer by the dentist or
305physician, patient, or other person not related to the insurer.
306d. The person receiving the procedure was not eligible to
307receive the procedure on the date of service.
308e. The services were provided during the grace period
309established under s. 627.608 or applicable federal regulations,
310and the [dental] insurer notified the dentist or physician
311[provider] that the patient was in the grace period when the
312dentist or physician [provider] requested eligibility or
313enrollment verification from the [dental] insurer, if such request
314was made.
315(b) This subsection applies to all contracts:
3161.Between a health insurer and a dentist which are
317delivered, issued, or renewed on or after January 1, 2025.
3182.Between a health insurer and a physician which are
319delivered, issued, or renewed on or after January 1, 2027.
320(c) The office has all rights and powers to enforce this
321subsection as provided by s. 624.307.
322(d) The commission may adopt rules to implement this
323subsection.
324Section 3. Subsections (13) and (14) of section 641.315,
325Florida Statutes, are amended to read:
326641.315 Provider contracts.—
327(13)(a) A contract between a health maintenance
328organization and a dentist licensed under chapter 466 or a
329physician licensed under chapter 458 or chapter 459 for the
330provision of services to a subscriber of the health maintenance
331organization may not specify credit card payment as the only
332acceptable method for payments from the health maintenance
333organization to the dentist or physician.
334(b) When a health maintenance organization employs the
335method of claims payment to a dentist or physician through
336electronic funds transfer, including, but not limited to,
337virtual credit card payment, the health maintenance organization
338shall notify the dentist or physician as provided in this
339paragraph and obtain the dentist’s or physician’s consent before
340employing the electronic funds transfer. The dentist’s or
341physician’s consent described in this paragraph applies to the
342dentist’s or physician’s entire practice. For the purpose of
343this paragraph, the dentist’s or physician’s consent, which may
344be given through e-mail, must bear the signature of the dentist
345or physician. Such signature includes an electronic or digital
346signature if the form of signature is recognized as a valid
347signature under applicable federal law or state contract law or
348an act that demonstrates express consent, including, but not
349limited to, checking a box indicating consent. The health
350maintenance organization or the dentist or physician may not
351require that a dentist’s or physician’s consent as described in
352this paragraph be made on a patient-by-patient basis. The
353notification provided by the health maintenance organization to
354the dentist or physician must include all of the following:
3551. The fees, if any, that are associated with the
356electronic funds transfer.
3572. The available methods of payment of claims by the health
358maintenance organization, with clear instructions to the dentist
359or physician on how to select an alternative payment method.
360(c) A health maintenance organization that pays a claim to
361a dentist or physician through automated clearing house transfer
362may not charge a fee solely to transmit the payment to the
363dentist or physician unless the dentist or physician has
364consented to the fee.
365(d) This subsection applies to all contracts:
3661.Between a health maintenance organization and a dentist
367which are delivered, issued, or renewed on or after January 1,
3682025.
3692.Between a health maintenance organization and a
370physician which are delivered, issued, or renewed on or after
371January 1, 2027.
372(e) The office has all rights and powers to enforce this
373subsection as provided by s. 624.307.
374(f) The commission may adopt rules to implement this
375subsection.
376(14)(a) A health maintenance organization may not deny any
377claim subsequently submitted by a dentist licensed under chapter
378466 or a physician licensed under chapter 458 or chapter 459 for
379procedures specifically included in a prior authorization unless
380at least one of the following circumstances applies for each
381procedure denied:
3821. Benefit limitations, such as annual maximums and
383frequency limitations not applicable at the time of the prior
384authorization, are reached subsequent to issuance of the prior
385authorization.
3862. The documentation provided by the person submitting the
387claim fails to support the claim as originally authorized.
3883. Subsequent to the issuance of the prior authorization,
389new procedures are provided to the patient or a change in the
390condition of the patient occurs such that the prior authorized
391procedure would no longer be considered medically necessary,
392based on the prevailing standard of care.
3934. Subsequent to the issuance of the prior authorization,
394new procedures are provided to the patient or a change in the
395patient’s condition occurs such that the prior authorized
396procedure would at that time have required disapproval pursuant
397to the terms and conditions for coverage under the patient’s
398plan in effect at the time the prior authorization was issued.
3995. The denial of the claim was due to one of the following:
400a. Another payor is responsible for payment.
401b. The dentist or physician has already been paid for the
402procedures identified in the claim.
403c. The claim was submitted fraudulently, or the prior
404authorization was based in whole or material part on erroneous
405information provided to the health maintenance organization by
406the dentist or physician, patient, or other person not related
407to the organization.
408d. The person receiving the procedure was not eligible to
409receive the procedure on the date of service.
410e. The services were provided during the grace period
411established under s. 627.608 or applicable federal regulations,
412and the [dental] insurer notified the dentist or physician
413[provider] that the patient was in the grace period when the
414dentist or physician [provider] requested eligibility or
415enrollment verification from the [dental] insurer, if such request
416was made.
417(b) This subsection applies to all contracts:
4181.Between a health maintenance organization and a dentist
419which are delivered, issued, or renewed on or after January 1,
4202025.
4212.Between a health maintenance organization and a
422physician which are delivered, issued, or renewed on or after
423January 1, 2027.
424(c) The office has all rights and powers to enforce this
425subsection as provided by s. 624.307.
426(d) The commission may adopt rules to implement this
427subsection.
428Section 4. Paragraph (n) of subsection (2) of section
429409.967, Florida Statutes, is amended to read:
430409.967 Managed care plan accountability.—
431(2) The agency shall establish such contract requirements
432as are necessary for the operation of the statewide managed care
433program. In addition to any other provisions the agency may deem
434necessary, the contract must require:
435(n) Provider dispute resolution.—Disputes between a plan
436and a provider must [may] be resolved as described in s. 408.7057.
437Section 5. Subsection (6) of section 627.64194, Florida
438Statutes, is amended to read:
439627.64194 Coverage requirements for services provided by
440nonparticipating providers; payment collection limitations.—
441(6) Any dispute with regard to the reimbursement to the
442nonparticipating provider of emergency or nonemergency services
443as provided in subsection (4) shall be resolved in a court of
444competent jurisdiction or through the mandatory [voluntary]
445dispute resolution process in s. 408.7057.
446Section 6. This act shall take effect July 1, 2026.