Senate Bill 440 (2022) — Overpayment of claims
SB 440
Florida Bills
Florida Senate - 2022 SB 440 By Senator Harrell 25-00704-22 2022440__ Page 1 of 5 CODING: Words stricken are deletions; words underlined are additions. A bill to be entitled 1
An act relating to overpayment of claims; amending ss. 2 627.6131 and 641.3155, F.S.; revising the timeframe 3 for submission of insurer and health maintenance 4 organization claims, respectively, for overpayment to 5 providers; conforming provisions to changes made by 6 the act; providing an effective date. 7 8 Be It Enacted by the Legislature of the State of Florida: 9 10
Section 1. Subsections (6) and (18) of
section 627.6131, 11 Florida Statutes, are amended to read: 12 627.6131 Payment of claims.— 13
(6) If a health insurer determines that it has made an 14 overpayment to a provider for services rendered to an insured, 15 the health insurer must make a claim for such overpayment to the 16 provider’s designated location. A health insurer that makes a 17 claim for overpayment to a provider under this
section shall 18 give the provider a written or electronic statement specifying 19 the basis for the retroactive denial or payment adjustment. The 20 insurer must identify the claim or claims, or overpayment claim 21 portion thereof, for which a claim for overpayment is submitted. 22 (
a) If an overpayment determination is the result of 23 retroactive review or audit of coverage decisions or payment 24 levels not related to fraud, a health insurer shall adhere to 25 the following procedures: 26 1. All claims for overpayment must be submitted to a 27 provider within 12 30 months after the health insurer’s payment 28 of the claim. A provider must pay, deny, or contest the health 29
Florida Senate - 2022 SB 440 25-00704-22 2022440__ Page 2 of 5 CODING: Words stricken are deletions; words underlined are additions. insurer’s claim for overpayment within 40 days after the receipt 30 of the claim. All contested claims for overpayment must be paid 31 or denied within 120 days after receipt of the claim. Failure to 32 pay or deny overpayment and claim within 140 days after receipt 33 creates an uncontestable obligation to pay the claim. 34 2.
A provider that denies or contests a health insurer’s 35 claim for overpayment or any portion of a claim shall notify the 36 health insurer, in writing, within 35 days after the provider 37 receives the claim that the claim for overpayment is contested 38 or denied.
The notice that the claim for overpayment is denied 39 or contested must identify the contested portion of the claim 40 and the specific reason for contesting or denying the claim and, 41 if contested, must include a request for additional information. 42 If the health insurer submits additional information, the health 43 insurer must, within 35 days after receipt of the request, mail 44 or electronically transfer the information to the provider. The 45 provider shall pay or deny the claim for overpayment within 45 46 days after receipt of the information.
The notice is considered 47 made on the date the notice is mailed or electronically 48 transferred by the provider. 49 3. The health insurer may not reduce payment to the 50 provider for other services unless the provider agrees to the 51 reduction in writing or fails to respond to the health insurer’s 52 overpayment claim as required by this paragraph. 53 4. Payment of an overpayment claim is considered made on 54 the date the payment was mailed or electronically transferred. 55 An overdue payment of a claim bears simple interest at the rate 56 of 12 percent per year.
Interest on an overdue payment for a 57 claim for an overpayment begins to accrue when the claim should 58
Florida Senate - 2022 SB 440 25-00704-22 2022440__ Page 3 of 5 CODING: Words stricken are deletions; words underlined are additions. have been paid, denied, or contested. 59 (
b) A claim for overpayment shall not be permitted beyond 60 30 months after the health insurer’s payment of a claim, except 61 that Claims for overpayment may be sought beyond the 12-month 62 period provided in this subsection that time from providers 63 convicted of fraud pursuant to s. 817.234. 64
(18) Notwithstanding the 30-month period provided in 65 subsection (6), all claims for overpayment submitted to a 66 provider licensed under
chapter 458,
chapter 459,
chapter 460, 67
chapter 461, or
chapter 466 must be submitted to the provider 68 within 12 months after the health insurer’s payment of the 69 claim. A claim for overpayment may not be permitted beyond 12 70 months after the health insurer’s payment of a claim, except 71 that claims for overpayment may be sought beyond that time from 72 providers convicted of fraud pursuant to s. 817.234. 73
Section 2. Subsections (5) and (16) of
section 641.3155, 74 Florida Statutes, are amended to read: 75 641.3155 Prompt payment of claims.— 76
(5) If a health maintenance organization determines that it 77 has made an overpayment to a provider for services rendered to a 78 subscriber, the health maintenance organization must make a 79 claim for such overpayment to the provider’s designated 80 location. A health maintenance organization that makes a claim 81 for overpayment to a provider under this
section shall give the 82 provider a written or electronic statement specifying the basis 83 for the retroactive denial or payment adjustment. The health 84 maintenance organization must identify the claim or claims, or 85 overpayment claim portion thereof, for which a claim for 86 overpayment is submitted. 87
Florida Senate - 2022 SB 440 25-00704-22 2022440__ Page 4 of 5 CODING: Words stricken are deletions; words underlined are additions. (
a) If an overpayment determination is the result of 88 retroactive review or audit of coverage decisions or payment 89 levels not related to fraud, a health maintenance organization 90 shall adhere to the following procedures: 91 1. All claims for overpayment must be submitted to a 92 provider within 12 30 months after the health maintenance 93 organization’s payment of the claim. A provider must pay, deny, 94 or contest the health maintenance organization’s claim for 95 overpayment within 40 days after the receipt of the claim.
All 96 contested claims for overpayment must be paid or denied within 97 120 days after receipt of the claim. Failure to pay or deny 98 overpayment and claim within 140 days after receipt creates an 99 uncontestable obligation to pay the claim. 100 2. A provider that denies or contests a health maintenance 101 organization’s claim for overpayment or any portion of a claim 102 shall notify the organization, in writing, within 35 days after 103 the provider receives the claim that the claim for overpayment 104 is contested or denied.
The notice that the claim for 105 overpayment is denied or contested must identify the contested 106 portion of the claim and the specific reason for contesting or 107 denying the claim and, if contested, must include a request for 108 additional information. If the organization submits additional 109 information, the organization must, within 35 days after receipt 110 of the request, mail or electronically transfer the information 111 to the provider. The provider shall pay or deny the claim for 112 overpayment within 45 days after receipt of the information.
The 113 notice is considered made on the date the notice is mailed or 114 electronically transferred by the provider. 115 3. The health maintenance organization may not reduce 116
Florida Senate - 2022 SB 440 25-00704-22 2022440__ Page 5 of 5 CODING: Words stricken are deletions; words underlined are additions. payment to the provider for other services unless the provider 117 agrees to the reduction in writing or fails to respond to the 118 health maintenance organization’s overpayment claim as required 119 by this paragraph. 120 4. Payment of an overpayment claim is considered made on 121 the date the payment was mailed or electronically transferred. 122 An overdue payment of a claim bears simple interest at the rate 123 of 12 percent per year.
Interest on an overdue payment for a 124 claim for an overpayment payment begins to accrue when the claim 125 should have been paid, denied, or contested. 126 (
b) A claim for overpayment shall not be permitted beyond 127 30 months after the health maintenance organization’s payment of 128 a claim, except that Claims for overpayment may be sought beyond 129 the 12-month period provided in this subsection that time from 130 providers convicted of fraud pursuant to s. 817.234. 131
(16) Notwithstanding the 30-month period provided in 132 subsection (5), all claims for overpayment submitted to a 133 provider licensed under
chapter 458,
chapter 459,
chapter 460, 134
chapter 461, or
chapter 466 must be submitted to the provider 135 within 12 months after the health maintenance organization’s 136 payment of the claim. A claim for overpayment may not be 137 permitted beyond 12 months after the health maintenance 138 organization’s payment of a claim, except that claims for 139 overpayment may be sought beyond that time from providers 140 convicted of fraud pursuant to s. 817.234. 141