House Bill 1015 introduces significant reforms to the insurance claims payment process and prior authorization requirements for healthcare services in Florida. The bill establishes a new section, 627.4193, which prohibits payment adjudicators from downcoding services ordered by in-network providers unless explicitly allowed in the participation agreement. It mandates that if downcoding is permitted, detailed notifications must be provided to the provider, including reasons for downcoding and potential payment amounts. The bill also emphasizes the necessity of reviewing medical records before downcoding and establishes a presumption in favor of the physician's determination regarding diagnoses and service orders. Additionally, it enhances the prior authorization process by requiring utilization review entities to implement electronic systems and ensuring timely decisions on requests, particularly for urgent services.

Moreover, the bill amends existing laws to streamline the claims process, reducing the timeframes for insurers to pay or deny claims and addressing overpayment claims. It establishes that once a provider grants access to a patient's electronic medical record, no further documentation can be requested, and claims must be processed within specified timelines. The bill also sets a permissible error ratio for claims payment violations, allowing fines only if exceeded, and prohibits insurers from denying claims based on prior authorizations unless certain conditions are met. Overall, HB 1015 aims to enhance transparency, protect healthcare providers from undue financial burdens, and ensure timely access to necessary medical services for patients.

Statutes affected:
H 1015 Filed: 627.42392, 627.6131, 641.3155