Bill > S1130

Introduced Session

An act relating to insurance claims payments to health care providers; creating s. 627.4193, F.S.; defining terms; prohibiting payment adjudicators from downcoding health care services under certain circumstances; providing exceptions; requiring payment adjudicators to provide certain information to the provider; prohibiting payment adjudicators from downcoding a service under certain circumstances; prohibiting payment adjudicators for downcoding orders by a licensed nurse; specifying that payment adjudicators are solely responsible for certain violations of law; requiring payment adjudicators to maintain downcoding policies on their websites; specifying requirements for such policies; requiring health insurers to ensure that their downcoding policies are updated and to ensure compliance with specified provisions on downcoding; authorizing investigations and actions against noncompliance; providing certain presumption in favor of physicians’ determinations regarding diagnoses of patients and service orders; providing the calculation of interest on health insurers’ nonpayment or underpayment due to downcoding; providing a cause of action for health care providers; amending s. 627.42392, F.S.; defining terms; revising the definition of the term “health insurer”; requiring certain utilization review entities to only use a certain prior authorization form; deleting provisions related to pharmacy benefits managers’ or health insurers’ requirement to use a specified prior authorization form; requiring utilization review entities to establish and offer a specified electronic prior authorization process; specifying requirements for such process; specifying that the provider is deemed to have supplied all information necessary for prior authorization under certain circumstances; specifying that additional information is deemed unnecessary under certain circumstances; prohibiting utilization review entities’ prior authorization process from requiring information that is not needed; requiring utilization review entities to disclose all prior authorization requirements and restrictions; requiring such requirements and restrictions to be explained in a specified manner; prohibiting utilization review entities from implementing certain new requirements or restrictions; providing exceptions; providing reporting requirements; requiring the Office of Insurance Regulation to publish on its website a report based on such entities’ reports; providing requirements for adverse determinations made by such entities on health care providers’ claims; providing a timeframe for such entities’ determination on claims; prohibiting prior authorization requirements under certain circumstances; prohibiting prior authorization revocations, limits, conditions, and restrictions under certain circumstances; providing exceptions; providing a timeframe for the validity of prior authorizations under certain circumstances; providing construction; amending ss. 627.6131 and 641.3155, F.S.; defining terms; revising the definition of the term “claim”; revising requirements and timeframes for responses from health insurers and health maintenance organizations, respectively, to submitted claims; revising the interest rate on overdue payments of claims; authorizing health care providers to refuse to participate in internal dispute resolution processes under certain circumstances; prohibiting health insurers and health maintenance organizations, respectively, from retrospectively, rather than retroactively, denying claims because of insured and enrollee ineligibility beyond a specified timeframe; revising such timeframe; revising applicability; providing construction; prohibiting health insurers and health maintenance organizations, respectively, from requesting or requiring certain information from health care providers under certain circumstances; providing causes of action for health care providers under certain circumstances; amending s. 395.1065, F.S.; conforming cross-references; providing an effective date.

AI Summary

Ralph Massullo (R)*, 

Introduced (on 01/13/2026)

Official Document