69O-158.004. Insurers to Provide HRS with Certain Information; Reimbursement; Failure to Comply

(1) Every health insurer shall, upon request of AHCA for any records or any information contained in such records, pertaining to the coverage of any individual under a health insurance policy or to the medical benefits paid by or claims made to any insurer pursuant to such policy, make all requested records and information available to AHCA when such individual is a recipient of medical assistance or is a person who is legally responsible for such a recipient.

(2) Information obtained pursuant to this rule and Rule 59G-7.0211, F.A.C., shall be exempt from Chapter 119, F.S. No official, agent, servant, or employee of either the Office or any insurer shall be permitted to make any use of the information furnished pursuant to this rule except for investigations and records made for the purposes of determining whether insurance or other benefits could be, have been or should have been claimed pursuant to an insurance policy or other agreement with respect to items of medical care and services received by a particular individual for which medical assistance has been provided by AHCA or would otherwise be provided by AHCA if not for the liability or an insurer.

(3) Within 30 days from the date of receipt, insurers shall respond to a request by AHCA that the insurer enter into an information reporting agreement or contract with AHCA. Insurers shall enter into information reporting agreements or contracts with AHCA within 90 days from the date of the receipt of the request unless exempted pursuant to paragraph 59G-7.0211(3)(d), F.A.C.

(4) Unless otherwise stipulated in its information reporting contract, an insurer shall furnish to AHCA all requested information within 30 days of the effective date of the contract.

(5) After furnishing the information as agreed, insurers may file with AHCA for reimbursement in the manner set forth in paragraph 59G-7.0211(3)(g), F.A.C.

(6) Failure by any insurer to comply with these rules and related Florida Statutes may subject that insurer to administrative penalties as prescribed in the applicable provision of the Florida Insurance Code. After the Office has been notified, pursuant to paragraph 59G-7.0211(3)(l), F.A.C., that an insurer has not complied with AHCA’s request, the Office shall immediately notify the offending insurer by certified mail that if the insurer is not in compliance within 30 days from the date of receipt of the certified letter, the Office may impose an administrative penalty in an amount not to exceed the statutory limit. Upon any subsequent failure of the insurer to timely respond to a request by AHCA, the Office may proceed to suspend or revoke the insurer’s certificate of authority. The Office shall keep AHCA informed as to the status of such proceedings and any resulting agreement by the insurer to comply.

Rulemaking Authority 409.910, 624.308 FS. Law Implemented 409.910, 624.307(1), 624.420, 624.421, 624.4211, 624.424(9), 624.444, 624.445, 641.23, 641.25, 641.261, 641.411, 641.45, 641.452 FS. History–New 11-14-89, Formerly 4-80.004, 4-158.004.