Florida Senate - 2026 SB 1130 By Senator Massullo 11-00698A-26 20261130__ Page 1 of 56 CODING: Words stricken are deletions; words underlined are additions. A bill to be entitled 1

An act relating to insurance claims payments to health 2 care providers; creating s. 627.4193, F.S.; defining 3 terms; prohibiting payment adjudicators from 4 downcoding health care services under certain 5 circumstances; providing exceptions; requiring payment 6 adjudicators to provide certain information to the 7 provider; prohibiting payment adjudicators from 8 downcoding a service under certain circumstances; 9 prohibiting payment adjudicators for downcoding orders 10 by a licensed nurse; specifying that payment 11 adjudicators are solely responsible for certain 12 violations of law; requiring payment adjudicators to 13 maintain downcoding policies on their websites; 14 specifying requirements for such policies; requiring 15 health insurers to ensure that their downcoding 16 policies are updated and to ensure compliance with 17 specified provisions on downcoding; authorizing 18 investigations and actions against noncompliance; 19 providing certain presumption in favor of physicians’ 20 determinations regarding diagnoses of patients and 21 service orders; providing the calculation of interest 22 on health insurers’ nonpayment or underpayment due to 23 downcoding; providing a cause of action for health 24 care providers; amending s. 627.42392, F.S.; defining 25 terms; revising the definition of the term “health 26 insurer”; requiring certain utilization review 27 entities to only use a certain prior authorization 28 form; deleting provisions related to pharmacy benefits 29

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 2 of 56 CODING: Words stricken are deletions; words underlined are additions. managers’ or health insurers’ requirement to use a 30 specified prior authorization form; requiring 31 utilization review entities to establish and offer a 32 specified electronic prior authorization process; 33 specifying requirements for such process; specifying 34 that the provider is deemed to have supplied all 35 information necessary for prior authorization under 36 certain circumstances; specifying that additional 37 information is deemed unnecessary under certain 38 circumstances; prohibiting utilization review 39 entities’ prior authorization process from requiring 40 information that is not needed; requiring utilization 41 review entities to disclose all prior authorization 42 requirements and restrictions; requiring such 43 requirements and restrictions to be explained in a 44 specified manner; prohibiting utilization review 45 entities from implementing certain new requirements or 46 restrictions; providing exceptions; providing 47 reporting requirements; requiring the Office of 48 Insurance Regulation to publish on its website a 49 report based on such entities’ reports; providing 50 requirements for adverse determinations made by such 51 entities on health care providers’ claims; providing a 52 timeframe for such entities’ determination on claims; 53 prohibiting prior authorization requirements under 54 certain circumstances; prohibiting prior authorization 55 revocations, limits, conditions, and restrictions 56 under certain circumstances; providing exceptions; 57 providing a timeframe for the validity of prior 58

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 3 of 56 CODING: Words stricken are deletions; words underlined are additions. authorizations under certain circumstances; providing 59 construction; amending ss. 627.6131 and 641.3155, 60 F.S.; defining terms; revising the definition of the 61 term “claim”; revising requirements and timeframes for 62 responses from health insurers and health maintenance 63 organizations, respectively, to submitted claims; 64 revising the interest rate on overdue payments of 65 claims; authorizing health care providers to refuse to 66 participate in internal dispute resolution processes 67 under certain circumstances; prohibiting health 68 insurers and health maintenance organizations, 69 respectively, from retrospectively, rather than 70 retroactively, denying claims because of insured and 71 enrollee ineligibility beyond a specified timeframe; 72 revising such timeframe; revising applicability; 73 providing construction; prohibiting health insurers 74 and health maintenance organizations, respectively, 75 from requesting or requiring certain information from 76 health care providers under certain circumstances; 77 providing causes of action for health care providers 78 under certain circumstances; amending s. 395.1065, 79 F.S.; conforming cross-references; providing an 80 effective date. 81 82 Be It Enacted by the Legislature of the State of Florida: 83 84

Section

Section 627.4193, Florida Statutes, is created 85 to read: 86 627.4193 Restrictions on health insurance reimbursement 87

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 4 of 56 CODING: Words stricken are deletions; words underlined are additions. downcoding.— 88

(1) As used in this section, the term: 89 (a) “Downcode” or “downcoding” means the alteration by a 90 payment adjudicator of a service code to another service code or 91 the alteration, addition, or deletion by a payment adjudicator 92 of a modifier, when the changed code or modifier is associated 93 with a lower payment amount than the service code or modifier 94 billed by the provider or facility. 95 (b) “Health insurer” means any entity that offers health 96 insurance coverage, whether through a fully insured plan or 97 self-insured plan or fund, including, as applicable: 98 1.

An authorized health insurer offering health insurance 99 as defined in s. 624.603, as well as any entity that offers a 100 commercial self-insurance fund as defined in s. 624.462(2) or 101 group self-insurance fund as described in s. 624.4621. 102 2. A health insurer that is subject to any provision of 103 this chapter, as well as any entity that offers a self-insurance 104 plan or a group self-insurance plan. 105 3. A managed care plan as defined in s. 409.962. 106 4.

A health maintenance organization as defined in s. 107 641.19. 108 (c) “Medical record” means the comprehensive collection of 109 documentation, including clinical notes, diagnostic reports, and 110 other relevant information, which supports the health care 111 services provided. 112 (d) “Participation agreement” means a written contract or 113 agreement between a health insurer and a provider which outlines 114 the terms and conditions of participation, reimbursement rates, 115 and other relevant details. 116

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 5 of 56 CODING: Words stricken are deletions; words underlined are additions. (e) “Payment adjudicator” means a health insurer or any 117 entity that provides, offers to provide, or administers payment 118 on behalf of a health insurer, as well any pharmacy benefit 119 manager as defined in s. 624.490(1), and any other individual or 120 entity that provides, offers to provide, or administers payment 121 for hospital services, outpatient services, medical services, 122 prescription drugs, or other health care services to a person 123 treated by a health care professional or facility in this state 124 under a policy, plan, or contract. 125 (f) “Provider” means any health care professional, 126 facility, or entity that submits claims for reimbursement for 127 covered health care services. 128

(2) Payment adjudicators are prohibited from downcoding a 129 health care service billed by, or on behalf of, a provider, if 130 the health care service was ordered by a provider that is in-131 network with the applicable health insurer, unless such 132 downcoding is otherwise expressly permitted under the 133 participation agreement between the health insurer and the 134 provider. 135

(3) If downcoding is expressly permitted under the 136 participation agreement, the payment adjudicator must provide 137 the following information to the provider before making its 138 initial payment or notice of denial of payment: 139 (

a) A statement indicating that the service code or 140 modifier billed by the provider or facility will be downcoded. 141 (

b) An explanation detailing the reasons for downcoding the 142 claim. This explanation must include a clear description of the 143 service codes or modifiers that were altered, added, or deleted, 144 if applicable. 145

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 6 of 56 CODING: Words stricken are deletions; words underlined are additions. (

c) The payment amount that the payment adjudicator would 146 otherwise make if the service code or modifier is not downcoded. 147 (

d) A statement that the provider may contest the 148 downcoding of the applicable service code or modifier by filing 149 a contestation with the payment adjudicator with respect to the 150 downcoding within 15 days after receipt of the notice of 151 downcoding. 152 (

e) A statement that by contesting the downcoding of the 153 applicable service code or modifier, the provider does not waive 154 any of its legal rights and claims against the health insurer or 155 payment adjudicator to the fullest extent permissible under law. 156

(4) Even if the participation agreement expressly permits 157 downcoding, a payment adjudicator is prohibited from downcoding 158 a service without first conducting a review of the associated 159 medical record to ensure the accuracy of the coding change. 160

(5) A payment adjudicator is prohibited from downcoding for 161 orders by a licensed nurse. 162

(6) Notwithstanding any provision in this section, a 163 payment adjudicator that proceeds to downcode a service code or 164 modifier, regardless of whether such downcoding is contested by 165 the provider, is solely responsible for any violations of law 166 associated with such downcoding. 167

(7) Payment adjudicators are required to maintain clear and 168 accessible downcoding policies on their official website. These 169 policies must include: 170 (

a) An overview of the circumstances under which downcoding 171 may occur. 172 (

b) The process and criteria used for conducting reviews of 173 downcoded claims, including the role of medical record review. 174

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c) Information about the internal mechanisms for ensuring 175 consistency and accuracy in downcoding practices. 176 (

d) Information regarding the processes for contesting with 177 the payment adjudicator the downcoding of a service code, which 178 processes must offer appeal rights for the provider and the 179 patient, and peer review by a licensed physician before the 180 downcoding. 181

(8) Health insurers shall ensure that their downcoding 182 policies are updated as needed to reflect any changes in 183 regulations, industry standards, or internal procedures. 184

(9) Health insurers shall ensure compliance with this 185

section and shall develop internal procedures to implement and 186 adhere to the requirements outlined in this section. 187

(10) Regulatory authorities, including, but not limited to, 188 the Office of Insurance Regulation, may investigate and take 189 appropriate actions in cases of noncompliance with this section. 190

(11) When a particular health care service is ordered by a 191 licensed physician, there is a presumption that the physician’s 192 determination regarding the diagnosis of the patient and any 193 service order by the physician is correct and sufficient, absent 194 a coding error which the health insurer must first verify with 195 the physician before downcoding for such error. 196

(12) If an applicable court, arbitration tribunal, or other 197 binding legal process determines that a claim was subject to an 198 inappropriate or impermissible downcoding, whether in breach of 199 contract, statute, common law, or otherwise, such that 200 nonpayment or underpayment of the original claim has occurred, 201 then in accordance with s. 627.6131, interest must be calculated 202 on the full total amount that should have been paid on the claim 203

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 8 of 56 CODING: Words stricken are deletions; words underlined are additions. as of the applicable time period for payment specified in s. 204 627.6131. 205

(13) For a violation of this section, a provider shall have 206 a private cause of action to proceed against the health insurer 207 or payment adjudicator in the applicable tribunal for the 208 violation. 209

Section

Section 627.42392, Florida Statutes, is amended 210 to read: 211 627.42392 Prior authorization.— 212

(1) As used in this section, the term: 213 (a) “Adverse determination” means a decision by a health 214 insurer or utilization review entity that the health care 215 services rendered, or proposed to be rendered, to a patient are 216 denied, reduced, or terminated.

The term does not include a 217 decision to deny, reduce, or terminate services that are 218 determined to have been billed in duplicate bills or that are 219 confirmed with the provider to have been billed in error. 220 (b) “Electronic prior authorization process” does not 221 include transmissions through a facsimile machine. 222 (c) “Emergency health care service” means medical 223 screening, examination, and evaluation by a physician, or, to 224 the extent permitted by applicable law, by other appropriate 225 personnel under the supervision of a physician, to determine 226 whether an emergency medical condition exists and, if it does, 227 the care, treatment, or surgery by a physician necessary to 228 relieve or eliminate the emergency medical condition, within the 229 service capability of the facility. 230 (d) “Emergency medical condition” means a medical condition 231 manifesting itself by acute symptoms of sufficient severity, 232

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 9 of 56 CODING: Words stricken are deletions; words underlined are additions. including severe pain, such that a prudent layperson who 233 possesses an average knowledge of health and medicine could 234 reasonably expect the absence of immediate medical attention to 235 result in any of the conditions listed in s. 395.002(8). 236 (e) “Health insurer” means any entity that offers health 237 insurance coverage, whether through a fully insured plan or 238 self-insured plan or fund, including, as applicable: 239 1.

An authorized health insurer offering health insurance 240 as defined in s. 624.603, as well as any entity that offers a 241 commercial self-insurance fund as defined in s. 624.462(2) or a 242 group self-insurance fund as described in s. 624.4621. 243 2. A health insurer that is subject to any provision of 244 this chapter, as well as any entity that offers a self-insurance 245 plan or a group self-insurance plan. 246 3. A managed care plan as defined in s. 409.962. 247 4.

A health maintenance organization as defined in s. 248 641.19. 249 (f) “Prior authorization” means the process by which 250 utilization review entities determine the medical necessity or 251 medical appropriateness of otherwise covered health care 252 services before the rendering of such health care services.

The 253 term also includes any requirement by a health insurer or 254 utilization review entity that an enrollee or a health care 255 provider notify the health insurer or utilization review entity 256 before the provision of a health care service. 257 (g) “Urgent health care service” means a health care 258 service that, if the timeframe for making a nonexpedited prior 259 authorization is applied, could, in the opinion of a physician 260 with knowledge of the patient’s medical condition: 261

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 10 of 56 CODING: Words stricken are deletions; words underlined are additions. 1. Seriously jeopardize the life or health of the patient 262 or the ability of the patient to regain maximum function; or 263 2.

Subject the patient to severe pain that cannot be 264 adequately managed without the care, treatment, or prescription 265 drugs that are the subject of the prior authorization request. 266 (h) “Utilization review activity” means any activity 267 prospective to, concurrent with, or retrospective to the 268 provision of a nonemergency health care service, to determine 269 whether payment must be made in full or is subject to an adverse 270 determination. Utilization review activity is prohibited: 271 1. To the extent restricted or prohibited by an agreement 272 with a health care provider; 273 2.

For an emergency health care service; or 274 3. For a service provided to a patient experiencing an 275 emergency medical condition. 276 (i) “Utilization review entity” means an entity permitted 277 under the applicable agreement with a health care provider or 278 otherwise permitted by a provider that does not have such an 279 agreement to perform utilization review activities or upon whose 280 behalf utilization review activities are performed, including, 281 as applicable: 282 1.

An authorized health insurer offering health insurance 283 as defined in s. 624.603, as well as any entity that offers a 284 commercial self-insurance fund as defined in s. 624.462(2) or 285 group self-insurance fund as described in s. 624.4621. 286 2. A health insurer that is subject to any provision of 287 this chapter, as well as any entity that offers a self-insurance 288 plan or a group self-insurance plan. 289 3. A managed care plan as defined in s. 409.962. 290

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 11 of 56 CODING: Words stricken are deletions; words underlined are additions. 4. A health maintenance organization as defined in s. 291 641.19. 292 5. A pharmacy benefit manager as defined in s. 624.490(1). 293 6.

Any other individual or entity that provides, offers to 294 provide, or administers payment for hospital services, 295 outpatient services, medical services, prescription drugs, or 296 other health care services to a person treated by a health care 297 professional or facility in this state under a policy, plan, 298 contract, or fund “health insurer” means an authorized insurer 299 offering health insurance as defined in s. 624.603, a managed 300 care plan as defined in s. 409.962(10), or a health maintenance 301 organization as defined in s. 641.19(12). 302

(2) Notwithstanding any other provision of law, a 303 utilization review entity that effective January 1, 2017, or six 304 (6) months after the effective date of the rule adopting the 305 prior authorization form, whichever is later, a health insurer, 306 or a pharmacy benefits manager on behalf of the health insurer, 307 which does not provide an electronic prior authorization process 308 for use by its contracted providers may, shall only use the 309 prior authorization form that has been approved by the Financial 310 Services Commission for granting a prior authorization for a 311 medical procedure, course of treatment, or prescription drug 312 benefit.

Such form must be no longer than may not exceed two 313 pages in length, excluding any instructions or guiding 314 documentation, and must include all clinical documentation 315 necessary for the utilization review entity health insurer to 316 make a decision. At a minimum, the form must include: (1) 317 sufficient patient information to identify the member, date of 318 birth, full name, and Health Plan ID number; (2) provider name, 319

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 12 of 56 CODING: Words stricken are deletions; words underlined are additions. address and phone number; (3) the medical procedure, course of 320 treatment, or prescription drug benefit being requested, 321 including the medical reason therefor, and all services tried 322 and failed; (4) any laboratory documentation required; and (5) 323 an attestation that all information provided is true and 324 accurate. 325

(3) The Financial Services Commission, in consultation with 326 the Agency for Health Care Administration, shall adopt by rule 327 guidelines for all prior authorization forms which ensure the 328 general uniformity of such forms. 329

(4) A utilization review entity shall establish and offer a 330 secure, interactive online electronic prior authorization 331 process to accept electronic prior authorization requests. The 332 electronic prior authorization process must allow a person 333 seeking a prior authorization the ability to upload 334 documentation if such documentation is required by the 335 utilization review entity to adjudicate the prior authorization 336 request.

Once a provider grants a health insurer access to a 337 patient’s electronic medical record, the provider is deemed to 338 have supplied all information necessary for prior authorization 339 of the health care service, including, without limitation, all 340 information that is reasonably required by the health insurer, 341 other than for an emergency health care service or for a service 342 provided to a patient who is experiencing an emergency medical 343 condition, in advance of the provision of service, and the 344 health insurer asserts is missing as of the date of such 345 service.

Additional information or documentation, regardless of 346 whether the utilization review entity requests any additional 347 information, is deemed unnecessary, and deemed not required, for 348

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 13 of 56 CODING: Words stricken are deletions; words underlined are additions. prior authorization of the health care service, and any request 349 for additional information or any position of the utilization 350 review entity or any third party acting on behalf of the 351 utilization review entity regarding any lack of information from 352 the provider is prohibited from being used to deny, pend, or 353 delay prior authorization of the health care service. 354 (5)

(4) Electronic prior authorization approvals do not 355 preclude benefit verification or medical review by the health 356 insurer under either the medical or pharmacy benefits. 357

(6) A utilization review entity’s prior authorization 358 process is prohibited from requiring information that is not 359 needed to make a determination or facilitate a determination of 360 medical necessity of the requested medical procedure, course of 361 treatment, or prescription drug benefit. 362

(7) A utilization review entity shall disclose all of its 363 prior authorization requirements and restrictions, including any 364 written clinical criteria, in a publicly accessible manner on 365 its website. These requirements and restrictions must be 366 explained in detail and in clear and ordinary terms. 367

(8) A utilization review entity is prohibited from 368 implementing any new requirements or restrictions and from 369 making changes to existing requirements or restrictions on 370 obtaining prior authorization unless: 371 (

a) The changes have been available on a publicly 372 accessible website for at least 60 days before they are 373 implemented; 374 (

b) Policyholders and health care providers affected by the 375 new requirements and restrictions or changes to the requirements 376 and restrictions are provided with a written notice of the 377

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 14 of 56 CODING: Words stricken are deletions; words underlined are additions. changes at least 60 days before they are implemented, with such 378 notice being delivered electronically or by other means as 379 agreed to by the policyholder or the health care provider; and 380 (

c) All applicable amendments to a provider’s agreement 381 with the applicable health insurer or utilization review entity 382 have been obtained and memorialized in a mutually agreed-upon 383 writing before such implementation. 384 (9)(

a) Utilization review entities shall, by March 31 of 385 each year, submit a report to the Office of Insurance Regulation 386 with the following data elements for the prior calendar year: 387 1. A list of all items and services requiring prior 388 authorization. 389 2. The percentage of standard prior authorization requests 390 approved by the utilization review entity, aggregated by item or 391 service. 392 3. The percentage of standard prior authorization requests 393 denied by the utilization review entity, aggregated by item or 394 service. 395 4.

The percentage of standard prior authorization requests 396 approved by the utilization review entity after appeal, 397 aggregated by item or service. 398 5. The percentage of prior authorizations when the 399 timeframe for review was extended and request approved, by item 400 or service. 401 6. The percentage of expedited prior authorization requests 402 approved by the utilization review entity, by item or service. 403 7. The percentage of expedited prior authorization requests 404 denied by the utilization review entity, by item or service. 405 8. The percentage of expedited prior authorization requests 406

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 15 of 56 CODING: Words stricken are deletions; words underlined are additions. approved by the utilization review entity after appeal, by item 407 or service. 408 9. The average and median time between submission of a 409 request for prior authorization and the utilization review 410 entity’s decision for standard prior authorizations, by item or 411 service. 412 10. The average and median time between submission of a 413 request for prior authorization and the utilization review 414 entity’s decision for expedited prior authorizations, by item or 415 service. 416 (

b) The Office of Insurance Regulation shall, by July 1 of 417 each year, publish a report on its website detailing the 418 information in paragraph (

a) submitted by utilization review 419 entities. 420

(10) Utilization review entities shall ensure that all 421 adverse determinations are made by a physician licensed under 422

chapter 458 or

chapter 459. The physician: 423 (

a) Must possess a current and valid nonrestricted license 424 to practice medicine in this state; 425 (

b) Must be of the same specialty as the physician who 426 typically manages the medical condition or disease or provides 427 the health care service involved in the request; 428 (

c) Must have at least 5 years of experience treating 429 patients with the medical condition or disease for which the 430 health care service is being requested; and 431 (

d) May not have any direct or indirect financial 432 arrangement with the utilization review entity that rewards or 433 incentivizes, financially or otherwise, such physician in any 434 way relating to adverse determinations. 435

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(11) Notice of an adverse determination must be provided by 436 e-mail to the health care provider that initiated the prior 437 authorization and to the patient. Notice required under this 438 subsection must include: 439 (

a) The name, title, e-mail address, and telephone number 440 of the physician responsible for making the adverse 441 determination. 442 (

b) Any written clinical criteria and any internal rule, 443 guideline, or protocol on which the utilization review entity 444 relied when making the adverse determination and the reasons 445 those provisions apply to the patient’s specific medical 446 circumstance. 447 (

c) Information for the patient and the patient’s health 448 care provider which describes the procedure through which the 449 patient or health care provider may request a copy of any report 450 developed by personnel performing the review that led to the 451 adverse determination. 452 (

d) Information that explains to the patient and the 453 patient’s health care provider the manner in which to appeal the 454 adverse determination. 455

(12) If a utilization review entity requires prior 456 authorization of a nonurgent health care service, the 457 utilization review entity must grant a prior authorization or 458 make an adverse determination and notify the patient and the 459 patient’s health care provider of the decision within 72 hours 460 after obtaining all necessary information to grant the prior 461 authorization or make the adverse determination. For purposes of 462 this subsection, the term “necessary information” includes the 463 results of any face-to-face clinical evaluation or second 464

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 17 of 56 CODING: Words stricken are deletions; words underlined are additions. opinion that may be required. 465

(13) A utilization review entity shall grant an expedited 466 prior authorization or make an expedited adverse determination 467 concerning an urgent health care service and notify the patient 468 and the patient’s health care provider of such expedited prior 469 authorization or adverse determination no later than 24 hours 470 after receiving all information needed to complete the review of 471 the requested urgent health care service. 472 (14)(

a) A utilization review entity is prohibited from 473 requiring prior authorization for: 474 1. Prehospital transportation; 475 2. Provision of an emergency health care service; or 476 3. Provision of a service to a patient who is experiencing 477 an emergency medical condition. 478 (

b) A utilization review entity is prohibited from 479 conducting utilization review activity, and from making any 480 adverse determinations, to the extent restricted or prohibited 481 by an agreement with a health care provider. A utilization 482 review entity is prohibited from performing any utilization 483 review activity, and from making any adverse determinations, 484 with respect to: 485 1. An emergency health care service; or 486 2. A service provided to a patient who experiences an 487 emergency medical condition. 488

(15) A utilization review entity is prohibited from 489 requiring prior authorization, and from making any adverse 490 determinations, for the provision of medications for opioid use 491 disorder. For purposes of this subsection, the term “medications 492 for opioid use disorder” means the use of medications, commonly 493

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 18 of 56 CODING: Words stricken are deletions; words underlined are additions. prescribed in combination with counseling and behavioral 494 therapies, to provide a comprehensive approach to the treatment 495 of opioid use disorder. FDA-approved medications used to treat 496 opioid addiction include, but are not limited to, methadone, 497 buprenorphine, alone or in combination with naloxone, and 498 extended-release injectable naltrexone. Types of behavioral 499 therapies include, but are not limited to, individual therapy, 500 group counseling, family behavior therapy, motivational 501 incentives, and other modalities. 502

(16) A utilization review entity is prohibited from 503 revoking, limiting, conditioning, or restricting a prior 504 authorization if care is provided within 45 business days after 505 the date the health care provider receives the prior 506 authorization. A utilization review entity must pay, or cause 507 payment to be made to, the health care provider, without any 508 prepayment review or prepayment audit before such payment, at 509 the contracted payment rate for a health care service provided 510 by the health care provider per the prior authorization, unless: 511 (

a) The health care provider knowingly and materially 512 misrepresented the health care service in the prior 513 authorization request with the specific intent to deceive and 514 obtain an unlawful payment from the utilization review entity; 515 (

b) The health care service was no longer a covered 516 benefit, and medical necessity did not constitute a basis for 517 such noncovered benefit status, on the day the health care 518 service was provided, and the utilization review entity notified 519 the health care provider in writing of these facts before the 520 health care service was provided; 521 (

c) The authorized service was never performed; or 522

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d) The patient was no longer enrolled under the applicable 523 health plan and, on that basis, was not eligible for health care 524 coverage from the applicable health insurer or self-insured plan 525 on the day the care was provided, and the utilization review 526 entity notified the health care provider in writing of these 527 facts before the health care service was provided. 528

(17) If a utilization review entity requires a prior 529 authorization for a health care service for the treatment of a 530 chronic or long-term care condition, the prior authorization 531 must remain valid for the length of the treatment, and the 532 utilization review entity is prohibited from requiring the 533 patient to obtain a prior authorization again for the health 534 care service. 535

(18) A utilization review entity is prohibited from 536 imposing an additional prior authorization requirement with 537 respect to a surgical or otherwise invasive procedure, or any 538 item furnished as part of the surgical or invasive procedure, if 539 the procedure or item is furnished during the perioperative 540 period of another procedure for which prior authorization was 541 granted by the health insurer. 542

(19) If there is a change in coverage or approval criteria 543 for a previously authorized health care service, the change in 544 coverage or approval criteria is prohibited from adversely 545 affecting an enrollee who received prior authorization before 546 the effective date of the change for the remainder of the 547 enrollee’s plan year. 548

(20) A utilization review entity shall continue to honor a 549 prior authorization it has granted to an enrollee when the 550 enrollee changes products under the same health insurer. 551

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(21) Any failure by a utilization review entity to comply 552 with the deadlines and other requirements specified in this 553

section will result in any health care services subject to 554 review being automatically deemed authorized by the utilization 555 review entity. 556

(22) Except as otherwise provided in paragraphs (16)(a)-557 (d), prior authorization constitutes a conclusive determination 558 of the medical necessity of the authorized health care service 559 and an irrevocable obligation to pay for such authorized health 560 care service. 561 (23)(

a) This

section prohibits an agreement with a health 562 care provider to restrict, limit, prohibit, or substitute a 563 utilization review activity or prior authorization. 564 (

b) Nothing in this

section may be construed to: 565 1. Limit in any way the restrictions or prohibitions on 566 adverse determinations under an agreement with a health care 567 provider, nor to imply permission for, or applicability of, 568 adverse determinations for emergency health care services. 569 2. Restrict, limit, or prohibit in any way prior 570 authorizations under an agreement between a provider and a 571 utilization review entity, nor to restrict, limit, or prohibit a 572 provider’s rights to contest, reject, or oppose any prior 573 authorization activities. 574

(24) For a violation of this section, a provider shall have 575 a private cause of action to proceed against the health insurer 576 or utilization review entity in the applicable tribunal for the 577 violation. 578

Section

Section 627.6131, Florida Statutes, is amended 579 to read: 580

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 21 of 56 CODING: Words stricken are deletions; words underlined are additions. 627.6131 Prompt payment of claims.— 581

(1) The contract must shall include the following 582 provision: “Time of Payment of Claims: After receiving written 583 proof of loss, the health insurer shall will pay monthly all 584 claims. Claims benefits then due for ...(type of benefit).... 585 Benefits for any other loss covered by this policy shall will be 586 paid as soon as the health insurer receives proper written 587 proof.” 588

(2) As used in this section, the term: 589 (a) “Claim” for a noninstitutional provider means a paper 590 HCFA 1500 claim form, or its successor, or an electronic billing 591 instrument submitted to the health insurer’s designated location 592 that consists of the ANSI ASC X12N 837P standard HCFA 1500 data 593 set, or its successor, that has all mandatory entries for a 594 physician licensed under

chapter 458,

chapter 459,

chapter 460, 595

chapter 461, or

chapter 463, or psychologists licensed under 596

chapter 490 or any appropriate billing instrument as designated 597 by the provider that has all mandatory entries for any other 598 noninstitutional provider.

For institutional providers, “claim” 599 means a paper CMS-1450 claim form, or its successor, or an 600 electronic billing instrument submitted to the health insurer’s 601 designated location that consists of the ANSI ASC X12N 837I 602 standard UB-92 data set, or its successor, with entries stated 603 as mandatory by the National Uniform Billing Committee. 604 (b) “Clean claim” means a completed form, or completed 605 electronic billing instrument, containing all information 606 required under the applicable form or electronic billing 607 instrument, as well as information reasonably required by the 608 health insurer, other than for emergency services and care as 609

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 22 of 56 CODING: Words stricken are deletions; words underlined are additions. defined in s. 395.002, in advance of the provision of service by 610 the health insurer to substantiate the claim. 611 (c) “Electronic medical record” means the digital record of 612 a patient’s information that may be accessed through electronic 613 means, via portal or other method of electronic access, which 614 may include information regarding the patient’s medical history, 615 medical condition, medical treatment, laboratory results, 616 diagnostic reports, and clinical notes. 617 (d) “Emergency health care services” has the same meaning 618 as “emergency services and care” as defined in s. 395.002. 619 (e) “Health insurer” means any entity that offers health 620 insurance coverage, whether through a fully insured plan or a 621 self-insured plan or fund, including, as applicable: 622 1.

An authorized health insurer offering health insurance 623 as defined in s. 624.603, as well as any entity that offers a 624 commercial self-insurance fund as defined in s. 624.462(2) or a 625 group self-insurance fund as described in s. 624.4621. 626 2.

A health insurer that is subject to any provision of 627 this chapter, as well as any entity that offers a self-insurance 628 plan or a group self-insurance plan. 629 (f) “Insured ineligibility” means that the insured was no 630 longer enrolled in the health plan at the time of receiving the 631 applicable service. 632 (g) “Overpayment” means payment made upon a claim that is: 633 1. Billed in error; 634 2. A duplicate claim; or 635 3. Billed for a service rendered to a patient despite 636 insured ineligibility. 637 638

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 23 of 56 CODING: Words stricken are deletions; words underlined are additions. A request for overpayment is limited to a billing error, 639 duplicate bill, or insured ineligibility. 640

(3) All claims for payment or overpayment, whether 641 electronic or nonelectronic: 642 (

a) Are considered received on the date the claim is 643 received by the health insurer at its designated claims-receipt 644 location or the date the claim for overpayment claim is received 645 by the provider at its designated location. 646 (

b) As to providers’ claims for payment, must be mailed or 647 electronically transferred to the primary health insurer within 648 6 months after the following have occurred: 649 1. Discharge for inpatient services or the date of service 650 for outpatient services; and 651 2.

The provider has been furnished with the correct name 652 and address of the patient’s health insurer. 653 654 All providers’ claims for payment, whether electronic or 655 nonelectronic, must be mailed or electronically transferred to 656 the secondary health insurer within 45 90 days after final 657 determination by the primary health insurer. A provider’s claim 658 is considered submitted on the date it is electronically 659 transferred or mailed. 660 (

c) Must not duplicate a claim previously submitted unless 661 it is determined that the original claim was not received or is 662 otherwise lost. 663

(4) For all electronically submitted claims, a health 664 insurer shall: 665 (

a) Within 24 hours after the beginning of the next 666 business day after receipt of the claim, provide to the 667

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 24 of 56 CODING: Words stricken are deletions; words underlined are additions. electronic source submitting the claim an electronic 668 acknowledgment of the receipt of the claim, accompanied by a 669 statement indicating the health insurer’s position as to whether 670 the claim is a clean claim or is missing any information that is 671 required under the applicable electronic billing instrument, as 672 described in paragraph (2)(a), or that was reasonably required 673 by the health insurer, other than for emergency health care 674 services, in advance of the provision of service to substantiate 675 to the electronic source submitting the claim, and the health 676 insurer asserts is missing as of the date of service. 677 (

b) Within 15 20 days after receipt of the claim, pay the 678 claim or notify a provider or designee if a claim is denied or 679 contested. Notice of the health­ insurer’s action on the claim 680 and payment of the claim is considered to be made on the date 681 the notice or payment was received by the provider mailed or 682 electronically transferred. 683 (c)1.

Notification of the health insurer’s determination of 684 a contested claim must be accompanied by an itemized list of any 685 additional information that is required under the applicable 686 billing instrument, as described in paragraph (2)(a), or that 687 was reasonably required by the health insurer, other than for 688 emergency health care services, in advance of the provision of 689 service to substantiate the claim, and the health insurer 690 asserts is missing as of the date of such service or documents 691 the insurer can reasonably determine are necessary to process 692 the claim. 693 2.

A provider must submit the additional information or 694 documentation, as specified on the itemized list, within 30 35 695 days after receipt of the notification of contestation unless, 696

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 25 of 56 CODING: Words stricken are deletions; words underlined are additions. within the 30-day period, the provider notifies the health 697 insurer of the provider’s position that a clean claim has been 698 submitted. Additional information is considered submitted on the 699 date it is electronically transferred or mailed. The health 700 insurer is prohibited from requesting may not request duplicate 701 documents. 702 (

d) For purposes of this subsection, electronic means of 703 transmission of claims, notices, documents, forms, and payments 704 shall be used to the greatest extent possible by the health 705 insurer and the provider. 706 (

e) A claim contested by the health insurer must be paid or 707 denied within 30 90 days after receipt of the additional 708 information requested claim. Failure to pay or deny a claim 709 within 90 120 days after receipt of the claim, regardless of 710 whether contested by the health insurer, creates an 711 uncontestable obligation to pay the claim as submitted by the 712 provider. 713

(5) For all nonelectronically submitted claims, a health 714 insurer shall: 715 (

a) Within 15 days following receipt of the claim Effective 716 November 1, 2003, provide to the provider or its designee: 717 1. An acknowledgment of receipt of the claim, accompanied 718 by a statement indicating the health insurer’s position as to 719 whether the claim is a clean claim or the claim is missing any 720 information that is required under the applicable paper billing 721 form, as described in paragraph (2)(a), or that was reasonably 722 required by the health insurer, other than for emergency health 723 care services, in advance of the provision of service to 724 substantiate the claim, and the health insurer asserts is 725

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 26 of 56 CODING: Words stricken are deletions; words underlined are additions. missing as of the date of service; or 726 2. within 15 days after receipt of the claim to the 727 provider or provide a provider within 15 days after receipt with 728 Electronic access to the status of the a submitted claim, which 729 status must indicate the health insurer’s position as to whether 730 the claim is a clean claim or missing any information described 731 in subparagraph 1. 732 (

b) Within 30 40 days after receipt of the claim, pay the 733 claim or notify a provider or designee if a claim is denied or 734 contested. Notice of the health insurer’s action on the claim 735 and payment of the claim is considered to be made on the date 736 the notice or payment was received by the provider mailed or 737 electronically transferred. 738 (c)1.

Notification of the health insurer’s determination of 739 a contested claim must be accompanied by an itemized list of any 740 additional information that is required under the applicable 741 form or billing instrument, as described in paragraph (2)(a), or 742 that was reasonably required by the health insurer, other than 743 for emergency health care services, in advance of the provision 744 of service to substantiate the claim, and the health insurer 745 asserts is missing as of the date of such service or documents 746 the insurer can reasonably determine are necessary to process 747 the claim. 748 2.

A provider must submit the additional information or 749 documentation, as specified on the itemized list, within 30 35 750 days after receipt of the notification of contestation unless, 751 within the 30-day period, the provider notifies the health 752 insurer of its position that a clean claim has been submitted. 753 Additional information is considered submitted on the date it is 754

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 27 of 56 CODING: Words stricken are deletions; words underlined are additions. electronically transferred or mailed. The health insurer is 755 prohibited from requesting may not request duplicate documents. 756 (

d) For purposes of this subsection, electronic means of 757 transmission of claims, notices, documents, forms, and payments 758 must shall be used to the greatest extent possible by the health 759 insurer and the provider. 760 (

e) A claim contested by the health insurer must be paid or 761 denied within 30 120 days after receipt of the additional 762 information requested claim. Failure to pay or deny a claim 763 within 90 140 days after receipt of the claim, regardless of 764 whether contested by the health insurer, creates an 765 uncontestable obligation to pay the claim as submitted by the 766 provider. 767

(6) Regardless of whether a claim has been submitted 768 electronically or nonelectronically, and notwithstanding any 769 other provision of this section: 770 (

a) Once a provider grants a health insurer access to a 771 patient’s electronic medical record, the provider is deemed to 772 have supplied all information necessary to pay the claim, 773 including, without limitation, all information that is required 774 under the applicable billing instrument and that was reasonably 775 required by the health insurer, other than for emergency health 776 care services, in advance of the provision of service to 777 substantiate the claim.

Additional information or documentation, 778 regardless of whether the health insurer requests any additional 779 information, is deemed unnecessary, and deemed not required for 780 payment of the claim, and any request for additional 781 information, and any position of the health insurer or any third 782 party acting on behalf of the health insurer regarding any lack 783

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 28 of 56 CODING: Words stricken are deletions; words underlined are additions. of information from the provider, is prohibited from being used 784 to deny, reduce, offset, withhold, pend, or delay payment of the 785 claim. 786 (

b) If notice of access to the electronic medical record 787 has been provided to the health insurer, the claim must be paid 788 or denied within 30 days of such notice to the health insurer. 789 Failure to pay or deny a claim for which the health insurer has 790 been provided notice of access to the electronic medical record 791 within 75 days after receipt of such notice creates an 792 uncontestable obligation to pay the claim as submitted by the 793 provider. 794 (7)

(6) If a health insurer determines that it has made an 795 overpayment to a provider for services rendered to an insured, 796 the health insurer must make an overpayment a claim for such 797 overpayment to the provider’s designated location. A health 798 insurer that makes an overpayment a claim for overpayment to a 799 provider under this

section shall give the provider a written or 800 electronic statement specifying the basis for the retrospective 801 retroactive denial or payment adjustment. The health insurer 802 must also identify the claim or claims, or portion thereof, as 803 to which the health insurer alleges overpayment claim, and the 804 specific invoice number submitted with or on the claim portion 805 thereof, for which a claim for overpayment is submitted.

Except 806 as provided in subparagraph (a)3., there may be no denial, 807 reduction, offset, withholding, pending, or delay of payment, or 808 other negative impact, regardless of whether by the health 809 insurer or any third party acting on behalf of such health 810 insurer, on payment of any other claim of the provider on the 811 basis of the overpayment allegation. 812

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 29 of 56 CODING: Words stricken are deletions; words underlined are additions. (

a) If an overpayment determination is the result of 813 retrospective retroactive review or retrospective audit of 814 coverage decisions or payment levels not related to fraud, a 815 health insurer must shall adhere to the following procedures: 816 1. All overpayment claims for overpayment must be received 817 by the submitted to a provider within 18 30 months after the 818 health insurer’s payment of the claim.

A provider must pay, 819 deny, or contest the health insurer’s claim for overpayment 820 claim within 40 days after the receipt of the overpayment claim. 821 All contested overpayment claims for overpayment must be paid or 822 denied within 120 days after receipt of the overpayment claim. 823 Failure to pay or deny an overpayment and claim within 140 days 824 after receipt creates an uncontestable obligation to pay the 825 overpayment claim. 826 2.

A provider that denies or contests a health insurer’s 827 overpayment claim for overpayment or any portion of an 828 overpayment a claim shall notify the health insurer, in writing, 829 within 40 35 days after the provider receives the overpayment 830 claim that such overpayment the claim for overpayment is 831 contested or denied.

The notice that the overpayment claim for 832 overpayment is denied or contested must identify the denied or 833 contested portion of the overpayment claim and the specific 834 reason for contesting or denying the overpayment claim and, if 835 contested, must include a request for additional information. If 836 the health insurer submits additional information, the health 837 insurer must, within 35 days after receipt of the request, mail 838 or electronically transfer the information to the provider.

The 839 provider shall pay or deny the overpayment claim for overpayment 840 within 45 days after receipt of the information. The notice from 841

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 30 of 56 CODING: Words stricken are deletions; words underlined are additions. the provider regarding denial or contestation of the overpayment 842 claim is considered made on the date the notice is mailed or 843 electronically transferred by the provider. 844 3.

The health insurer is prohibited from denying, reducing, 845 offsetting, withholding, pending, or delaying may not reduce 846 payment to the provider for other services unless the provider 847 agrees to the denial, reduction, offset, withholding, pending, 848 or delay of payment in writing or fails to respond to the health 849 insurer’s overpayment claim as required by this paragraph. 850 4. Payment of an overpayment claim is considered made on 851 the date the payment was mailed or electronically transferred. 852 An overdue payment of a claim bears simple interest at the rate 853 of 12 percent per year.

Interest on an overdue payment for an 854 overpayment a claim for an overpayment begins to accrue when the 855 overpayment claim should have been paid, denied, or contested. 856 (

b) An overpayment A claim is prohibited for overpayment 857 shall not be permitted beyond 18 30 months after the health 858 insurer’s payment of a claim, except that overpayment claims for 859 overpayment may be sought beyond that time from providers 860 convicted of fraud pursuant to s. 817.234. 861 (8)

(7) Payment of a claim is considered made on the date 862 the payment was mailed or electronically transferred. An overdue 863 payment of a claim bears simple interest of 15 12 percent per 864 year, to be calculated on the full total amount that should have 865 been paid on the claim within the applicable time period 866 specified in this section. If an applicable court, arbitration 867 tribunal, or other binding legal process determines that a claim 868 that was paid at a lesser amount should have been paid at a full 869 total amount, whether under a breach of contract legal claim, a 870

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 31 of 56 CODING: Words stricken are deletions; words underlined are additions. legal claim under a statutory private cause of action, or other 871 basis, the 15 percent per year interest must be calculated on 872 the full total amount, rather than upon the difference between 873 the full total amount and the amount that was actually paid.

If 874 an applicable court, arbitration tribunal, or other binding 875 legal process determines that a claim was subject to an 876 inappropriate or impermissible denial or partial denial, whether 877 in a breach of contract, statute, common law, or otherwise, 878 interest must be calculated on the full total amount that should 879 have been paid on the claim within the applicable time period 880 for payment specified in this section, and the act of denial or 881 partial denial is deemed not to have in any way tolled the time 882 period for such payment.

Interest on the full total amount that 883 should have been paid on the claim within the applicable time 884 period specified in this

section an overdue payment for a claim 885 or for any portion of a claim begins to accrue when the claim 886 should have been paid, denied, or contested. The interest must 887 be paid along with, and in addition to, the payment for the 888 satisfaction of the full total amount of the claim, as 889 determined by an applicable court, arbitration tribunal, or 890 other binding legal process is payable with the payment of the 891 claim. 892 (9)

(8) For all contracts entered into or renewed on or 893 after October 1, 2002, a health insurer’s internal dispute 894 resolution process related to a denied claim not under active 895 review by a mediator, arbitrator, or third-party dispute entity 896 must be finalized within 60 days after the receipt of the 897 provider’s request for review or appeal. Notwithstanding any 898 provision of this section, when the provider and health insurer 899

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 32 of 56 CODING: Words stricken are deletions; words underlined are additions. disagree as to

interpretation of contractual or statutory 900 language, the provider is not required to participate in the 901 health insurer’s internal dispute resolution process. 902 (10)

(9) A provider or any representative of a provider, 903 regardless of whether the provider is under contract with the 904 health insurer, is prohibited from collecting or attempting may 905 not collect or attempt to collect money from, maintaining 906 maintain any action at law against, or reporting report to a 907 credit agency an insured for payment of covered services for 908 which the health insurer contested or denied the provider’s 909 claim.

This prohibition applies during the pendency of any claim 910 for payment made by the provider to the health insurer for 911 payment of the services or internal dispute resolution process 912 to determine whether the health insurer is liable for the 913 services. For a claim, this pendency applies from the date the 914 claim or a portion of the claim is denied to the date of the 915 completion of the health insurer’s internal dispute resolution 916 process, not to exceed 60 days.

This subsection does not 917 prohibit the collection by the provider of copayments, 918 coinsurance, or deductible amounts due the provider. 919

(10) The provisions of this

section may not be waived, 920 voided, or nullified by contract. 921

(11) A health insurer is prohibited from retrospectively 922 denying may not retroactively deny a claim because of insured 923 ineligibility more than 90 days 1 year after the date of payment 924 of the claim. 925

(12) A health insurer must shall pay a contracted primary 926 care or admitting physician, pursuant to such physician’s 927 contract, for providing inpatient services in a contracted 928

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 33 of 56 CODING: Words stricken are deletions; words underlined are additions. hospital to an insured if such services are determined by such 929 physician the health insurer to be medically necessary and, 930 regardless of the health plan’s determination of medical 931 necessity, are otherwise covered services under the health 932 insurer’s contract with the contract holder. 933

(13) Upon written notification by an insured, a health an 934 insurer shall investigate any claim of improper billing of the 935 insured by a physician, hospital, or other health care provider 936 for a health care service alleged to not actually have been 937 received. The health insurer shall determine whether if the 938 insured actually received the applicable service was properly 939 billed for only those procedures and services that the insured 940 actually received.

If the health insurer determines that the 941 insured did not actually receive the applicable service has been 942 improperly billed, the health insurer must shall notify the 943 insured and the provider of its findings and must shall reduce 944 the amount of payment to the provider by the amount for the 945 service that was not actually received determined to be 946 improperly billed. If a reduction is made due to such 947 notification by the insured, the insurer shall pay to the 948 insured 20 percent of the amount of the reduction up to $500. 949

(14) A permissible error ratio of 5 percent is established 950 for health insurer’s claims payment violations of paragraphs 951 (4)(a), (b), (c), and (

e) and (5)(a), (b), (c), and (e). If the 952 error ratio of a particular health insurer does not exceed the 953 permissible error ratio of 5 percent for an audit period, no 954 fine may shall be assessed for the noted claims violations for 955 the audit period. The error ratio is shall be determined by 956 dividing the number of claims with violations found on a 957

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 34 of 56 CODING: Words stricken are deletions; words underlined are additions. statistically valid sample of claims for the audit period by the 958 total number of claims in the sample. If the error ratio exceeds 959 the permissible error ratio of 5 percent, a fine may be assessed 960 according to s. 624.4211 for those claims payment violations 961 which exceed the error ratio. Notwithstanding the provisions of 962 this section, the office may fine a health insurer for claims 963 payment violations of paragraphs (4)(

e) and (5)(

e) which create 964 an uncontestable obligation to pay the claim as submitted by the 965 provider. The office shall refrain from imposing a not fine upon 966 a health insurer insurers for violations which the office 967 determines were due to circumstances beyond the health insurer’s 968 control. 969

(15) This

section is applicable only to a major medical 970 expense health insurance policy as defined in s. 627.643(2)(e) 971 offered by a group or an individual health insurer licensed 972 under pursuant to

chapter 624, including a preferred provider 973 policy under s. 627.6471 and an exclusive provider organization 974 under s. 627.6472 or a group or individual insurance contract 975 that only provides direct payments to dentists for enumerated 976 dental services, or other health insurance coverage, policy, or 977 fund, regardless of whether fully insured or self-insured, 978 offered or administered by a health insurer. 979

(16) Notwithstanding paragraph (4)(b), where an electronic 980 pharmacy claim is submitted to a pharmacy benefits manager 981 acting on behalf of a health insurer, the pharmacy benefits 982 manager shall, within 30 days of receipt of the claim, pay the 983 claim or notify a provider or designee if a claim is denied or 984 contested. Notice of the health insurer’s action on the claim 985 and payment of the claim is considered to be made on the date 986

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 35 of 56 CODING: Words stricken are deletions; words underlined are additions. the notice or payment was received by the provider mailed or 987 electronically transferred. 988

(17) Notwithstanding paragraph (5)(a), effective November 989 1, 2003, where a nonelectronic pharmacy claim is submitted to a 990 pharmacy benefits manager acting on behalf of a health insurer, 991 the pharmacy benefits manager shall provide acknowledgment of 992 receipt of the claim within 30 days after receipt of the claim 993 to the provider or provide a provider within 30 days after 994 receipt with electronic access to the status of a submitted 995 claim. 996

(18) Notwithstanding the 18-month 30-month period provided 997 in subsection (7) (6), all overpayment claims for overpayment 998 submitted to a provider licensed under

chapter 395,

chapter 458, 999

chapter 459,

chapter 460,

chapter 461,

chapter 463,

chapter 466, 1000 or

chapter 490 must be submitted to the provider within 12 1001 months after the health insurer’s payment of the claim. An 1002 overpayment A claim to a provider licensed under

chapter 395, 1003

chapter 458,

chapter 459,

chapter 460,

chapter 461,

chapter 463, 1004

chapter 466, or

chapter 490 is prohibited for overpayment may 1005 not be permitted beyond 12 months after the health insurer’s 1006 payment of a claim, except that overpayment claims for 1007 overpayment may be sought beyond that time from providers 1008 convicted of fraud pursuant to s. 817.234. 1009

(19) Notwithstanding any other provision of this section, 1010 all claims for underpayment from a provider licensed under 1011

chapter 395,

chapter 458,

chapter 459,

chapter 460,

chapter 461, 1012 or

chapter 466 must be submitted to the health insurer within 12 1013 months after the health insurer’s payment of the claim. A claim 1014 for underpayment by a provider licensed under

chapter 395, 1015

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 36 of 56 CODING: Words stricken are deletions; words underlined are additions.

chapter 458,

chapter 459,

chapter 460,

chapter 461, or

chapter 1016 466 is prohibited may not be permitted beyond 12 months after 1017 the health insurer’s payment of a claim. 1018

(20) Nothing in this

section shall be interpreted to limit, 1019 restrict, or negatively impact any legal claim by a provider or 1020 health insurer for breach of contract, statutory or regulatory 1021 violation, or a common-law cause of action, nor to shorten or 1022 otherwise negatively impact the statute of limitations timeframe 1023 for bringing any such legal claim. 1024

(21) A health insurer is prohibited from requesting 1025 information from a contracted or noncontracted provider which 1026 does not apply to the medical condition at issue for the 1027 purposes of adjudicating a clean claim. 1028

(22) A health insurer is prohibited from requesting a 1029 contracted or noncontracted provider to resubmit claim 1030 information that the contracted or noncontracted provider can 1031 document it has already provided to the health insurer or that 1032 is contained inside the electronic medical record to which the 1033 health insurer has been provided access. 1034

(23) Notwithstanding any other provision of this section, a 1035 health insurer is prohibited from requiring any information from 1036 a provider before the provision of emergency health care 1037 services as a condition of payment of a claim, as a basis for 1038 denying, delaying, offsetting, withholding, or reducing payment 1039 of a claim, or in contesting whether the claim is a clean claim. 1040

(24) For a violation of this section, a provider shall have 1041 a private cause of action to proceed against the health insurer 1042 in the applicable tribunal for the violation. 1043 (25)(20)(

a) A contract between a health insurer and a 1044

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 37 of 56 CODING: Words stricken are deletions; words underlined are additions. dentist licensed under

chapter 466 for the provision of services 1045 to an insured is prohibited from specifying may not specify 1046 credit card payment as the only acceptable method for payments 1047 from the health insurer to the dentist. 1048 (

b) When a health insurer employs the method of claims 1049 payment to a dentist through electronic funds transfer, 1050 including, but not limited to, virtual credit card payment, the 1051 health insurer shall notify the dentist as provided in this 1052 paragraph and obtain the dentist’s consent before employing the 1053 electronic funds transfer. The dentist’s consent described in 1054 this paragraph applies to the dentist’s entire practice.

For the 1055 purpose of this paragraph, the dentist’s consent, which may be 1056 given through e-mail, must bear the signature of the dentist. 1057 Such signature includes an electronic or digital signature if 1058 the form of signature is recognized as a valid signature under 1059 applicable federal law or state contract law or

an act that 1060 demonstrates express consent, including, but not limited to, 1061 checking a box indicating consent. The health insurer or dentist 1062 is prohibited from requiring may not require that a dentist’s 1063 consent as described in this paragraph be made on a patient-by-1064 patient basis. The notification provided by the health insurer 1065 to the dentist must include all of the following: 1066 1. The fees, if any, associated with the electronic funds 1067 transfer. 1068 2. The available methods of payment of claims by the health 1069 insurer, with clear instructions to the dentist on how to select 1070 an alternative payment method. 1071 (

c) A health insurer that pays a claim to a dentist through 1072 automated clearinghouse transfer is prohibited from charging may 1073

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 38 of 56 CODING: Words stricken are deletions; words underlined are additions. not charge a fee solely to transmit the payment to the dentist 1074 unless the dentist has consented to the fee. 1075 (

d) This subsection applies to contracts delivered, issued, 1076 or renewed on or after January 1, 2025. 1077 (

e) The office has all rights and powers to enforce this 1078 subsection as provided by s. 624.307. 1079 (

f) The commission may adopt rules to implement this 1080 subsection. 1081 (26)(21)(

a) A health insurer is prohibited from denying may 1082 not deny any claim subsequently submitted by a dentist licensed 1083 under

chapter 466 for procedures specifically included in a 1084 prior authorization unless at least one of the following 1085 circumstances applies for each procedure denied: 1086 1. Benefit limitations, such as annual maximums and 1087 frequency limitations not applicable at the time of the prior 1088 authorization, are reached subsequent to issuance of the prior 1089 authorization. 1090 2. The documentation provided by the person submitting the 1091 claim fails to support the claim as originally authorized. 1092 3.

Subsequent to the issuance of the prior authorization, 1093 new procedures are provided to the patient or a change in the 1094 condition of the patient occurs such that the prior authorized 1095 procedure would no longer be considered medically necessary, 1096 based on the prevailing standard of care. 1097 4.

Subsequent to the issuance of the prior authorization, 1098 new procedures are provided to the patient or a change in the 1099 patient’s condition occurs such that the prior authorized 1100 procedure would at that time have required disapproval pursuant 1101 to the terms and conditions for coverage under the patient’s 1102

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 39 of 56 CODING: Words stricken are deletions; words underlined are additions. plan in effect at the time the prior authorization was issued. 1103 5. The denial of the claim was due to one of the following: 1104 a. Another payor is responsible for payment. 1105 b. The dentist has already been paid for the procedures 1106 identified in the claim. 1107 c.

The claim was submitted fraudulently, or the prior 1108 authorization was based in whole or material part on erroneous 1109 information provided to the health insurer by the dentist, 1110 patient, or other person not related to the health insurer. 1111 d. The person receiving the procedure was not eligible to 1112 receive the procedure on the date of service. 1113 e.

The services were provided during the grace period 1114 established under s. 627.608 or applicable federal regulations, 1115 and the dental insurer notified the provider that the patient 1116 was in the grace period when the provider requested eligibility 1117 or enrollment verification from the dental insurer, if such 1118 request was made. 1119 (

b) This subsection applies to all contracts delivered, 1120 issued, or renewed on or after January 1, 2025. 1121 (

c) The office has all rights and powers to enforce this 1122 subsection as provided by s. 624.307. 1123 (

d) The commission may adopt rules to implement this 1124 subsection. 1125

Section

Section 641.3155, Florida Statutes, is amended 1126 to read: 1127 641.3155 Prompt payment of claims.— 1128

(1) As used in this section, the term: 1129 (a) “Claim” for a noninstitutional provider means a paper 1130 HCFA 1500 claim form, or its successor, or an electronic billing 1131

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 40 of 56 CODING: Words stricken are deletions; words underlined are additions. instrument submitted to the health maintenance organization’s 1132 designated location that consists of the ANSI ASC X12N 837P 1133 standard HCFA 1500 data set, or its successor, that has all 1134 mandatory entries for a physician licensed under

chapter 458, 1135

chapter 459,

chapter 460,

chapter 461, or

chapter 463, or 1136 psychologists licensed under

chapter 490 or any appropriate 1137 billing instrument as designated by the provider that has all 1138 mandatory entries for any other noninstitutional provider.

For 1139 institutional providers, “claim” means a paper CMS-1450 claim 1140 form, or its successor, or an electronic billing instrument 1141 submitted to the health maintenance organization’s designated 1142 location that consists of the ANSI ASC X12N 837I standard UB-92 1143 data set or its successor with entries stated as mandatory by 1144 the National Uniform Billing Committee. 1145 (b) “Clean claim” means a completed form, or completed 1146 electronic billing instrument, containing all information 1147 required under the applicable form or electronic billing 1148 instrument, as well as information reasonably required by the 1149 health maintenance organization, other than for emergency 1150 services and care as defined in s. 641.19, in advance of the 1151 provision of service by the health maintenance organization to 1152 substantiate the claim. 1153 (c) “Electronic medical record” means the digital record of 1154 a patient’s information that may be accessed through electronic 1155 means, via portal or other method of electronic access, which 1156 may include information regarding the patient’s medical history, 1157 medical condition, medical treatment, laboratory results, 1158 diagnostic reports, and clinical notes. 1159 (d) “Emergency health care service” has the same meaning as 1160

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 41 of 56 CODING: Words stricken are deletions; words underlined are additions. “emergency services and care” as defined in s. 641.19. 1161 (e) “Enrollee ineligibility” means that the enrollee was no 1162 longer enrolled in the health maintenance organization at the 1163 time of receiving the applicable service. 1164 (f) “Overpayment” means payment made upon a claim that is: 1165 1. Billed in error; 1166 2. A duplicate claim; or 1167 3. Billed for a service rendered to a patient despite 1168 enrollee ineligibility. 1169 1170 A request for overpayment is limited to a billing error, 1171 duplicate bill, or enrollee ineligibility. 1172

(2) All claims for payment or overpayment, whether 1173 electronic or nonelectronic: 1174 (

a) Are considered received on the date the claim is 1175 received by the health maintenance organization at its 1176 designated claims-receipt location or the date the overpayment a 1177 claim for overpayment is received by the provider at its 1178 designated location. 1179 (

b) As to providers’ claims for payment, must be mailed or 1180 electronically transferred to the primary organization within 6 1181 months after the following have occurred: 1182 1. Discharge for inpatient services or the date of service 1183 for outpatient services; and 1184 2. The provider has been furnished with the correct name 1185 and address of the patient’s health maintenance organization. 1186 1187 All providers’ claims for payment, whether electronic or 1188 nonelectronic, must be mailed or electronically transferred to 1189

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 42 of 56 CODING: Words stricken are deletions; words underlined are additions. the secondary organization within 45 90 days after final 1190 determination by the primary organization. A provider’s claim is 1191 considered submitted on the date it is electronically 1192 transferred or mailed. 1193 (

c) Must not duplicate a claim previously submitted unless 1194 it is determined that the original claim was not received or is 1195 otherwise lost. 1196

(3) For all electronically submitted claims, a health 1197 maintenance organization shall: 1198 (

a) Within 24 hours after the beginning of the next 1199 business day after receipt of the claim, provide to the 1200 electronic source submitting the claim an electronic 1201 acknowledgment of the receipt of the claim, accompanied by a 1202 statement indicating the health maintenance organization’s 1203 position as to whether the claim is a clean claim or whether the 1204 claim is missing any information that is required under the 1205 applicable electronic billing instrument described in paragraph 1206 (1)(

a) or that was reasonably required by the health maintenance 1207 organization, other than for emergency health care services, in 1208 advance of the provision of service to substantiate to the 1209 electronic source submitting the claim, and the health 1210 maintenance organization asserts is missing as of the date of 1211 service. 1212 (

b) Within 15 20 days after receipt of the claim, pay the 1213 claim or notify a provider or designee if a claim is denied or 1214 contested. Notice of the health maintenance organization’s 1215 action on the claim and payment of the claim is considered to be 1216 made on the date the notice or payment was received by the 1217 provider mailed or electronically transferred. 1218

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 43 of 56 CODING: Words stricken are deletions; words underlined are additions. (c)1. Notification of the health maintenance organization’s 1219 determination of a contested claim must be accompanied by an 1220 itemized list of any additional information required under the 1221 applicable billing instrument described in paragraph (1)(

a) or 1222 that was reasonably required by the health maintenance 1223 organization, other than for emergency health care services, in 1224 advance of the provision of service to substantiate the claim, 1225 and the health maintenance organization asserts is missing as of 1226 the date of such service or documents the insurer can reasonably 1227 determine are necessary to process the claim. 1228 2.

A provider must submit the additional information or 1229 documentation, as specified on the itemized list, within 30 35 1230 days after receipt of the notification of contestation unless, 1231 within the 30-day period, the provider notifies the health 1232 maintenance organization of the provider’s position that a clean 1233 claim has been submitted. Additional information is considered 1234 submitted on the date it is electronically transferred or 1235 mailed. The health maintenance organization is prohibited from 1236 requesting may not request duplicate documents. 1237 (

d) For purposes of this subsection, electronic means of 1238 transmission of claims, notices, documents, forms, and payment 1239 shall be used to the greatest extent possible by the health 1240 maintenance organization and the provider. 1241 (

e) A claim contested by the health maintenance 1242 organization must be paid or denied within 30 90 days after 1243 receipt of the additional information requested claim. Failure 1244 to pay or deny a claim within 90 120 days after receipt of the 1245 claim, regardless of whether contested by the health maintenance 1246 organization, creates an uncontestable obligation to pay the 1247

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 44 of 56 CODING: Words stricken are deletions; words underlined are additions. claim. 1248

(4) For all nonelectronically submitted claims, a health 1249 maintenance organization shall: 1250 (

a) Within 15 days following receipt of the claim Effective 1251 November 1, 2003, provide to the provider, or designee, who 1252 submitted the claim: 1253 1.

An acknowledgment of receipt of the claim, accompanied 1254 by a statement indicating the health maintenance organization’s 1255 position as to whether the claim is a clean claim or the claim 1256 is missing any information that is required under the applicable 1257 paper billing form, as described in paragraph (1)(a), or that 1258 was reasonably required by the health maintenance organization, 1259 other than for emergency health care services, in advance of the 1260 provision of service to substantiate the claim, and the health 1261 maintenance organization asserts is missing as of the date of 1262 service; or 1263 2. within 15 days after receipt of the claim to the 1264 provider or designee or provide a provider or designee within 15 1265 days after receipt with Electronic access to the status of the a 1266 submitted claim, which status must indicate the health 1267 maintenance organization’s position as to whether the claim is a 1268 clean claim or missing any information described in subparagraph 1269 1. 1270 (

b) Within 30 40 days after receipt of the claim, pay the 1271 claim or notify a provider or designee if a claim is denied or 1272 contested. Notice of the health maintenance organization’s 1273 action on the claim and payment of the claim is considered to be 1274 made on the date the notice or payment was received by the 1275 provider mailed or electronically transferred. 1276

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 45 of 56 CODING: Words stricken are deletions; words underlined are additions. (c)1.

Notification of the health maintenance organization’s 1277 determination of a contested claim must be accompanied by an 1278 itemized list of any additional information required under the 1279 applicable form or billing instrument described in paragraph 1280 (1)(a), or that was reasonably required by the health 1281 maintenance organization, other than for emergency health care 1282 services, in advance of the provision of service to substantiate 1283 the claim, and the health maintenance organization asserts is 1284 missing as of the date of such service or documents the 1285 organization can reasonably determine are necessary to process 1286 the claim. 1287 2.

A provider must submit the additional information or 1288 documentation, as specified on the itemized list, within 30 35 1289 days after receipt of the notification of contestation unless, 1290 within the 30-day period, the provider notifies the health 1291 maintenance organization of the provider’s position that a clean 1292 claim has been submitted. Additional information is considered 1293 submitted on the date it is electronically transferred or 1294 mailed. The health maintenance organization is prohibited from 1295 requesting may not request duplicate documents. 1296 (

d) For purposes of this subsection, electronic means of 1297 transmission of claims, notices, documents, forms, and payments 1298 must shall be used to the greatest extent possible by the health 1299 maintenance organization and the provider. 1300 (

e) A claim contested by the health maintenance 1301 organization must be paid or denied within 30 120 days after 1302 receipt of the additional information requested claim. Failure 1303 to pay or deny a claim within 90 140 days after receipt of the 1304 claim, regardless of whether contested by the health maintenance 1305

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 46 of 56 CODING: Words stricken are deletions; words underlined are additions. organization, creates an uncontestable obligation to pay the 1306 claim as submitted by the provider. 1307

(5) Regardless of whether a claim has been submitted 1308 electronically or nonelectronically, and notwithstanding any 1309 other provision of this section: 1310 (

a) Once a provider grants a health maintenance 1311 organization access to a patient’s electronic medical record, 1312 the provider is deemed to have supplied all information 1313 necessary to pay the claim, including, without limitation, all 1314 information that is required under the applicable billing 1315 instrument and that was reasonably required by the health 1316 maintenance organization, other than for emergency health care 1317 services, in advance of the provision of service to substantiate 1318 the claim.

Additional information or documentation, regardless 1319 of whether the health maintenance organization requests any 1320 additional information, is deemed unnecessary and deemed not 1321 required for payment of the claim, and any request for 1322 additional information, and any position of the health 1323 maintenance organization or any third party acting on behalf of 1324 the health maintenance organization regarding any lack of 1325 information from the provider, is prohibited from being used to 1326 deny, reduce, offset, withhold, pend, or delay payment of the 1327 claim. 1328 (

b) If notice of access to the electronic medical record 1329 has been provided to the health maintenance organization, the 1330 claim must be paid or denied within 30 days of such notice to 1331 the health maintenance organization. Failure to pay or deny a 1332 claim, for which the health maintenance organization has been 1333 provided notice of access to the electronic medical record 1334

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 47 of 56 CODING: Words stricken are deletions; words underlined are additions. within 75 days after receipt of such notice, creates an 1335 uncontestable obligation to pay the claim as submitted by the 1336 provider. 1337 (6)

(5) If a health maintenance organization determines that 1338 it has made an overpayment to a provider for services rendered 1339 to an enrollee a subscriber, the health maintenance organization 1340 must make an overpayment a claim for such overpayment to the 1341 provider’s designated location. A health maintenance 1342 organization that makes an overpayment a claim for overpayment 1343 to a provider under this

section shall give the provider a 1344 written or electronic statement specifying the basis for the 1345 retrospective retroactive denial or payment adjustment. The 1346 health maintenance organization must also identify the claim or 1347 claims, or overpayment claim portion thereof, as to which the 1348 health maintenance organization alleges overpayment, and the 1349 specific invoice number submitted with or on the claim, as well 1350 as the specific line items on the bill that are subject to the 1351 overpayment claim for which a claim for overpayment is 1352 submitted.

Except as provided in subparagraph (a)3., there may 1353 be no denial, reduction, offset, withholding, pending, or delay 1354 of payment, or other negative impact, regardless of whether by 1355 the health maintenance organization or any third party acting on 1356 behalf of such health maintenance organization, on payment of 1357 any other claim of the provider on the basis of the overpayment 1358 allegation. 1359 (

a) If an overpayment determination is the result of 1360 retrospective retroactive review or retrospective audit of 1361 coverage decisions or payment levels not related to fraud, a 1362 health maintenance organization must shall adhere to the 1363

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 48 of 56 CODING: Words stricken are deletions; words underlined are additions. following procedures: 1364 1. All overpayment claims for overpayment must be received 1365 by the submitted to a provider within 18 30 months after the 1366 health maintenance organization’s payment of the claim. A 1367 provider must pay, deny, or contest the health maintenance 1368 organization’s overpayment claim for overpayment within 40 days 1369 after the receipt of the overpayment claim.

All contested 1370 overpayment claims for overpayment must be paid or denied within 1371 120 days after receipt of the overpayment claim. Failure to pay 1372 or deny an overpayment and claim within 140 days after receipt 1373 creates an uncontestable obligation to pay the overpayment 1374 claim. 1375 2.

A provider that denies or contests a health maintenance 1376 organization’s overpayment claim for overpayment or any portion 1377 of an overpayment a claim shall notify the health maintenance 1378 organization, in writing, within 40 35 days after the provider 1379 receives the overpayment claim that the overpayment claim for 1380 overpayment is contested or denied.

The notice that the 1381 overpayment claim for overpayment is denied or contested must 1382 identify the denied or contested portion of the claim and the 1383 specific reason for contesting or denying the overpayment claim 1384 and, if contested, must include a request for additional 1385 information. If the health maintenance organization submits 1386 additional information, the health maintenance organization 1387 must, within 35 days after receipt of the request, mail or 1388 electronically transfer the information to the provider.

The 1389 provider shall pay or deny the overpayment claim for overpayment 1390 within 45 days after receipt of the information. The notice from 1391 the provider regarding denial or contestation of the overpayment 1392

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 49 of 56 CODING: Words stricken are deletions; words underlined are additions. claim is considered made on the date the notice is mailed or 1393 electronically transferred by the provider. 1394 3.

The health maintenance organization is prohibited from 1395 denying, reducing, offsetting, withholding, pending, or delaying 1396 may not reduce payment to the provider for other services unless 1397 the provider agrees to the denial, reduction, offset, 1398 withholding, pending, or delay of payment in writing or fails to 1399 respond to the health maintenance organization’s overpayment 1400 claim as required by this paragraph. 1401 4.

Payment of an overpayment claim is considered made on 1402 the date the payment was mailed or electronically transferred. 1403 An overdue payment of a claim bears simple interest at the rate 1404 of 12 percent per year. Interest on an overdue payment for an 1405 overpayment a claim for an overpayment payment begins to accrue 1406 when the overpayment claim should have been paid, denied, or 1407 contested. 1408 (

b) An overpayment A claim is prohibited for overpayment 1409 shall not be permitted beyond 18 30 months after the health 1410 maintenance organization’s payment of a claim, except that 1411 overpayment claims for overpayment may be sought beyond that 1412 time from providers convicted of fraud pursuant to s. 817.234. 1413 (7)

(6) Payment of a claim is considered made on the date 1414 the payment was mailed or electronically transferred to the 1415 provider. An overdue payment of a claim bears simple interest of 1416 15 12 percent per year, to be calculated on the full total 1417 amount that should have been paid on the claim within the 1418 applicable time period specified in this section. If an 1419 applicable court, arbitration tribunal, or other binding legal 1420 process determines that a claim that was paid at a lesser amount 1421

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 50 of 56 CODING: Words stricken are deletions; words underlined are additions. should have been paid at a full total amount, whether under a 1422 breach of contract legal claim, a legal claim under a statutory 1423 private cause of action, or other basis, the 15 percent per year 1424 interest must be calculated on the full total amount, rather 1425 than upon the difference between the full total amount and the 1426 amount that was actually paid.

If an applicable court, 1427 arbitration tribunal, or other binding legal process determines 1428 that a claim was subject to an inappropriate or impermissible 1429 denial or partial denial, whether in a breach of contract, 1430 statute, common law, or otherwise, interest must be calculated 1431 on the full total amount that should have been paid on the claim 1432 within the applicable time period for payment specified in this 1433 section, and the act of denial or partial denial is deemed not 1434 to have in any way tolled the time period for such payment. 1435 Interest on the full total amount that should have been paid on 1436 the claim within the applicable time period specified in this 1437

section an overdue payment for a claim or for any portion of a 1438 claim begins to accrue when the claim should have been paid, 1439 denied, or contested. The interest must be paid along with, and 1440 in addition to, the payment for the satisfaction of the full 1441 total amount of the claim, as determined by an applicable court, 1442 arbitration tribunal, or other binding legal process is payable 1443 with the payment of the claim. 1444 (8)

(7) For all contracts entered into or renewed on or 1445 after October 1, 2002, a health maintenance organization’s 1446 internal dispute resolution process related to a denied claim 1447 not under active review by a mediator, arbitrator, or third-1448 party dispute entity must be finalized within 60 days after the 1449 receipt of the provider’s request for review or appeal. 1450

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 51 of 56 CODING: Words stricken are deletions; words underlined are additions. Notwithstanding any provision of this section, if the provider 1451 and health maintenance organization disagree as to the 1452

interpretation of contractual or statutory language, the 1453 provider is not required to participate in the health 1454 maintenance organization’s internal dispute resolution process. 1455 (9)

(8) A provider or any representative of a provider, 1456 regardless of whether the provider is under contract with the 1457 health maintenance organization, is prohibited from collecting 1458 or attempting may not collect or attempt to collect money from, 1459 maintaining maintain any action at law against, or reporting 1460 report to a credit agency an enrollee a subscriber for payment 1461 of covered services for which the health maintenance 1462 organization contested or denied the provider’s claim.

This 1463 prohibition applies during the pendency of any claim for payment 1464 made by the provider to the health maintenance organization for 1465 payment of the services or internal dispute resolution process 1466 to determine whether the health maintenance organization is 1467 liable for the services. For a claim, this pendency applies from 1468 the date the claim or a portion of the claim is denied to the 1469 date of the completion of the health maintenance organization’s 1470 internal dispute resolution process, not to exceed 60 days.

This 1471 subsection does not prohibit collection by the provider of 1472 copayments, coinsurance, or deductible amounts due the provider. 1473

(9) The provisions of this

section may not be waived, 1474 voided, or nullified by contract. 1475

(10) A health maintenance organization is prohibited from 1476 retrospectively denying may not retroactively deny a claim 1477 because of enrollee subscriber ineligibility more than 90 days 1 1478 year after the date of payment of the claim. 1479

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 52 of 56 CODING: Words stricken are deletions; words underlined are additions.

(11) A health maintenance organization must shall pay a 1480 contracted primary care or admitting physician, pursuant to such 1481 physician’s contract, for providing inpatient services in a 1482 contracted hospital to an enrollee a subscriber if such services 1483 are determined by the primary care physician or admitting 1484 physician health maintenance organization to be medically 1485 necessary and such services are covered services under the 1486 health maintenance organization’s contract with the contract 1487 holder. 1488

(12) A permissible error ratio of 5 percent is established 1489 for health maintenance organizations’ claims payment violations 1490 of paragraphs (3)(a), (b), (c), and (

e) and (4)(a), (b), (c), 1491 and (e). If the error ratio of a particular health maintenance 1492 organization insurer does not exceed the permissible error ratio 1493 of 5 percent for an audit period, no fine may shall be assessed 1494 for the noted claims violations for the audit period. The error 1495 ratio is shall be determined by dividing the number of claims 1496 with violations found on a statistically valid sample of claims 1497 for the audit period by the total number of claims in the 1498 sample.

If the error ratio exceeds the permissible error ratio 1499 of 5 percent, a fine may be assessed according to s. 624.4211 1500 for those claims payment violations which exceed the error 1501 ratio. Notwithstanding the provisions of this section, the 1502 office may fine a health maintenance organization for claims 1503 payment violations of paragraphs (3)(

e) and (4)(

e) which create 1504 an uncontestable obligation to pay the claim as submitted by the 1505 provider. The office shall refrain from imposing a not fine upon 1506 a health maintenance organization organizations for violations 1507 which the office determines were due to circumstances beyond the 1508

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 53 of 56 CODING: Words stricken are deletions; words underlined are additions. organization’s control. 1509

(13) This

section applies shall apply to all claims or any 1510 portion of a claim submitted for payment for services provided 1511 to an enrollee by a health maintenance organization subscriber 1512 under a health maintenance organization plan, or submitted for 1513 payment for services provided to an enrollee under a self-1514 insured plan or fund, or fully-insured plan or fund, offered by 1515 a person or an entity, when a health maintenance organization is 1516 involved in the administration, or claims-processing activities, 1517 relating to such plan or fund subscriber contract to the 1518 organization for payment. 1519

(14) Notwithstanding paragraph (3)(b), where an electronic 1520 pharmacy claim is submitted to a pharmacy benefits manager 1521 acting on behalf of a health maintenance organization, the 1522 pharmacy benefits manager must shall, within 30 days after of 1523 receipt of the claim, pay the claim or notify a provider or 1524 designee if a claim is denied or contested. Notice of the health 1525 maintenance organization’s action on the claim and payment of 1526 the claim is considered to be made on the date the notice or 1527 payment was received by the provider mailed or electronically 1528 transferred. 1529

(15) Notwithstanding paragraph (4)(a), effective November 1530 1, 2003, where a nonelectronic pharmacy claim is submitted to a 1531 pharmacy benefits manager acting on behalf of a health 1532 maintenance organization, the pharmacy benefits manager shall 1533 provide acknowledgment of receipt of the claim within 30 days 1534 after receipt of the claim to the provider or provide a provider 1535 within 30 days after receipt with electronic access to the 1536 status of a submitted claim. 1537

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 54 of 56 CODING: Words stricken are deletions; words underlined are additions.

(16) Notwithstanding the 18-month 30-month period provided 1538 in subsection (6) (5), all claims for overpayment submitted to a 1539 provider licensed under

chapter 395,

chapter 458,

chapter 459, 1540

chapter 460,

chapter 461,

chapter 463,

chapter 466, or

chapter 1541 490 must be submitted to the provider within 12 months after the 1542 health maintenance organization’s payment of the claim. An 1543 overpayment A claim to a provider licensed under

chapter 395, 1544 458,

chapter 459,

chapter 460,

chapter 461,

chapter 463,

chapter 1545 466, or

chapter 490 is prohibited for overpayment may not be 1546 permitted beyond 12 months after the health maintenance 1547 organization’s payment of a claim, except that claims for 1548 overpayment may be sought beyond that time from providers 1549 convicted of fraud pursuant to s. 817.234. 1550

(17) Notwithstanding any other provision of this section, 1551 all claims for underpayment from a provider licensed under 1552

chapter 395,

chapter 458,

chapter 459,

chapter 460,

chapter 461, 1553 or

chapter 466 must be submitted to the health maintenance 1554 organization within 12 months after the health maintenance 1555 organization’s payment of the claim. A claim for underpayment by 1556 a provider licensed under

chapter 395,

chapter 458,

chapter 459, 1557

chapter 460,

chapter 461, or

chapter 466 is prohibited may not 1558 be permitted beyond 12 months after the health maintenance 1559 organization’s payment of a claim. 1560

(18) Nothing in this

section may be interpreted to limit, 1561 restrict, or negatively impact any legal claim by a provider or 1562 health maintenance organization for breach of contract, 1563 statutory or regulatory violation, or a common-law cause of 1564 action, nor to shorten or otherwise negatively impact the 1565 statute of limitations timeframe for bringing any such legal 1566

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 55 of 56 CODING: Words stricken are deletions; words underlined are additions. claim. 1567

(19) A health insurer is prohibited from requesting 1568 information from a contracted or noncontracted provider which 1569 does not apply to the medical condition at issue for the 1570 purposes of adjudicating a clean claim. 1571

(20) A health maintenance organization is prohibited from 1572 requesting a contracted or noncontracted provider to resubmit 1573 claim information that the contracted or noncontracted provider 1574 can document it has already provided to the health maintenance 1575 organization or that is contained inside the electronic medical 1576 record to which the health maintenance organization has been 1577 provided access. 1578

(21) Notwithstanding any other provision of this section, a 1579 health maintenance organization is prohibited from requiring any 1580 information from a provider before the provision of emergency 1581 health care services as a condition of payment of a claim, as a 1582 basis for denying, delaying, offsetting, withholding, or 1583 reducing payment of a claim, or in contesting whether the claim 1584 is a clean claim. 1585

(22) For a violation of this section, a provider shall have 1586 a private cause of action to proceed against the health 1587 maintenance organization in the applicable tribunal for the 1588 violation. 1589

Section 5. Paragraph (

c) of subsection (2) of

section 1590 395.1065, Florida Statutes, is amended to read: 1591 395.1065 Criminal and administrative penalties; 1592 moratorium.— 1593 (2) 1594 (

c) The agency may impose an administrative fine for the 1595

Florida Senate - 2026 SB 1130 11-00698A-26 20261130__ Page 56 of 56 CODING: Words stricken are deletions; words underlined are additions. violation of s. 641.3154 or, if sufficient claims due to a 1596 provider from a health maintenance organization do not exist to 1597 enable the take-back of an overpayment, as provided under s. 1598 641.3155(6) s. 641.3155(5), for the violation of s. 641.3155(6) 1599 s. 641.3155(5). The administrative fine for a violation cited in 1600 this paragraph shall be in the amounts specified in s. 1601 641.52(5), and the provisions of paragraph (

a) do not apply. 1602

Section 6. This act shall take effect July 1, 2026. 1603