69O-203.055. Claim Payments

In order to assure subscriber reimbursement, when applicable, and to prevent unauthorized billing by providers to the subscribers of the PLHSO, the PLHSO shall pay promptly all valid claims from subscribers or providers. The following standards shall apply, and failure to meet these standards shall be cause for examination as provided by Section 636.039, F.S.

(1) Each PLHSO shall pay claims for authorized referrals within 30 days of receipt by the PLHSO of the claim from the referral provider. If additional information is needed, the PLHSO shall request the additional information in writing within 30 days of receipt of the claim. If additional information is requested, the PLHSO shall affirm and pay any clean claim within 30 days of receipt of the additional information.

(2) Each PLHSO shall pay claims for emergency services within 30 days from receipt of the claim unless additional information is requested to evaluate the claim. If additional information is needed, the PLHSO shall request the additional information in writing within 30 days of receipt of the claim. Each PLHSO shall affirm and pay any valid claim within 30 days of receipt of the additional information, or deny coverage of the claim within the same 30 day period. If the claim is denied, the PLHSO shall provide written justification for the denial to both the subscriber and to any providers involved.

Specific Authority 636.067 FS. Law Implemented 636.059, 641.3903 FS. History–New 11-15-94, Formerly 4-203.055.