AGENCY FOR HEALTH CARE ADMINISTRATION
Health Facility and Agency Licensing
RULE NO.:RULE TITLE:
59A-12.030Statewide Provider and Health Plan Claim Dispute Resolution Program
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 43 No. 59, March 27, 2017 issue of the Florida Administrative Register.
59A-12.030 Statewide Provider and Health Plan Claim Dispute Resolution Program.
(1) through (3) No change.
(4) Claim Dispute Review.
(a) The Agency shall approve the review cost fee schedule proposed by the resolution organization.
(a)(b) The entity that does not prevail in the agency’s final order must pay the review costs.
(b)(c) In the event that both parties prevail in part, the review fee shall be apportioned in proportion to the final judgement. The apportionment shall be based on the disputed claim amount.
(c)(d) If the non-prevailing party or parties fail to pay the ordered review costs within 35 days after the agency’s final order, the non-paying party or parties are subject to a penalty of $500 per day.
(5) through (6) No change.
(7) Hearing Process
(a) through (b) No change.
(c) Each party is responsible for its own legal fees
(8) Resolution Organization Review and Decision Process.
(a) through (b) No change.
(c) The resolution organization shall require the respondent in the claim dispute to submit all documentation in support of its position within 15 days after receiving a request from the resolution organization for supporting documentation. The resolution organization may extend the time if appropriate. Failure to submit the supporting documentation within such time period shall result in a default against the health plan or provider. In the event of such a default, the resolution organization shall issue its written recommendation to the Agency that a default be entered against the defaulting entity. The written recommendation shall include a recommendation to the Agency that the defaulting entity shall pay the entity submitting the claim dispute the full amount of the claim dispute, plus all accrued interest, and shall be considered a nonprevailing party for the purposes of this section. Any additional information submitted by the adverse party to the resolution organization must be submitted to the entity filing the request for dispute resolution at the same time.
(d) through- (h) No change.
Rulemaking Authority 408.7057 and 409.961 FS. Law Implemented 408.7057 and 409.967 FS. History–New 10-23-00, Amended 3-28-01, 11-11-02,__________.
