59A-12.030. Statewide Provider and Health Plan Claim Dispute Resolution Program

(1) Definitions.

(a) “Contracted provider” means a provider who is  under a contractual agreement with a health plan.

(b) “Disputed Claim” means a claim that has been submitted by a provider to the health plan or by a health plan to a provider for payment and has been denied in full or in part, or is presumed to have been underpaid or overpaid.

(c)“Disputed Claim Amount” means the difference between the expected reimbursement amount and the reimbursement received.

(d) “Health Plan” as defined in Section 408.7057(1)(b), F.S., or a managed care or long term care plan procured pursuant to Section 409.966, F.S.

(e) “Non-contracted provider” means a provider that does not have a contractual agreement with a health plan.

(f) “Provider” as defined in Section 641.19(15), F.S., means any physician, hospital, institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state. Includes both contracted and non-contracted providers.

(g) “Professional services” means occupations that require special training or holding a professional license not classified as hospital inpatient or outpatient services.

(h) “Resolution organization” means a qualified independent third-party claim-dispute resolution entity selected by and contracted with the Agency for Health Care Administration.

(2) Purpose.

(a) To establish a program to provide assistance to providers and health plans for resolution of claim disputes that are not resolved by the provider and the health plans.

(b) The following claim disputes can be submitted by providers or health plans:

1. Claims disputed for services rendered after October 1, 2000.

2. Claims disputes related to payment amounts only, provider disputes payment amount received, or health plan disputes regarding payback amount.

3. Providers are required to aggregate claims by type of service to meet certain minimum thresholds in accordance with paragraph 59A-12.030(5)(c), F.A.C.

(c) The resolution organization shall provide assistance to providers and health plans for resolution of claim disputes within the parameters of Section 408.7057, F.S.

(d) The resolution organization shall hear submitted claims disputes in accordance with the provisions of Section 408.7057, F.S., and this rule.

(3) Resolution Organization.

(a) The resolution organization shall determine, based on a desk review, whether the claim disputes submitted by the health plans or providers meet the statutory requirements of Section 408.7057(2), F.S.

(b) The resolution organization shall inform the Agency on the status of all claim disputes.

(4) Claim Dispute Review.

(a) The entity that does not prevail in the agency’s final order must pay the review costs.

(b) 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) 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) Jurisdictional Amounts and Methods of Aggregation for Claim Disputes.

(a) Claims submitted for dispute resolution shall be submitted separately by the following claim categories:

1. Hospital inpatient services claims.

2. Hospital outpatient services claims.

3. Professional services claims.

(b) Either the provider or the health plan may make an offer to settle the claim dispute.

(c) Entities filing a request for dispute resolution shall be permitted to aggregate claims. The minimum disputed claim amounts for claims submitted to the resolution organization shall be as follows:

1. Hospital inpatient services. Disputed individual claim amounts must be aggregated to a total amount of $25,000 for health plan contracted hospitals and $10,000 for non-contracted hospitals.

2. Hospital outpatient services. Disputed individual claim amounts must be aggregated to a total amount of $10,000 for health plan contracted hospitals, and $3,000 for non-contracted hospitals.

3. Professional services. Disputed individual claim amounts shall be aggregated to a minimum amount of $500.

(d) Rural hospitals as defined in Section 395.602(2)(e), F.S., filing requests for claim dispute resolution, are exempt from the minimum disputed claim amounts specified in subparagraphs (5)(c)1. and 2., of this rule.

(e) The offer to settle the claim dispute must state the total amount and the party to whom it is directed has 15 days to accept the offer once it is received.

(f) If the party receiving the offer does not accept the offer and the final order amount is more than 90 percent or less than 110 percent of the offer amount, the party receiving the offer must pay the final order amount to the offering party and is deemed a non-prevailing party for purposes of this section.

(g) The amount of an offer made by a provider to settle an alleged underpayment by the health plan must be greater than 110 percent of the reimbursement amount the provider received.

(h) The amount of an offer made by a health plan to settle an alleged overpayment to the provider must be less than 90 percent of the alleged overpayment amount by the health plan.

(i) Both parties may agree to settle the disputed claim at any time, for any amount, regardless of whether an offer to settle was made or rejected.

(6) Application Process.

(a) The resolution organization shall review claim disputes filed by either the providers or health plans. A request for dispute resolution and supporting documentation must be submitted in hard copy or electronically to the resolution organization in a format prescribed by the resolution organization.

(b) A complete copy of the request, including all supporting documentation, must be submitted to the adverse party at the same time.

(c) The resolution organization must review all requests for claim dispute resolution within 10 days after receipt to determine whether the request meets the statutory and rule criteria for submission to the resolution organization as specified in Sections 408.7057(2)(b)1.-7. and (d), F.S.

(d) If the resolution organization determines that the dispute resolution request does not meet the statutory and rule criteria, the request shall be returned to the entity filing the request.

(7) Hearing Process.

(a) Either party may request that the resolution organization conduct an evidentiary hearing in which both sides can present evidence and examine witnesses, and for which the cost of hearing is equally shared by the parties.

(b) In the event witnesses are called to testify, it is the responsibility of both parties to pay for its own witnesses.

(8) Resolution Organization Review and Decision Process.

(a) The resolution organization must review and consider all documentation submitted by both the health plan and the provider. The resolution organization must notify the entity requesting the dispute resolution and the adverse party electronically or by mail that the request for dispute resolution has been accepted for review.

(b) If the resolution organization determines that the documentation provided with the initial application is not sufficient, it may request additional documents from the entity filing the request for dispute resolution. The resolution organization shall require the health plan or provider submitting the claim dispute to submit any supporting documentation to the resolution organization within 15 days after receipt by the health plan or provider of a request from the resolution organization for documentation in support of the claim dispute. Failure to submit the supporting documentation within such time period shall result in the dismissal of the submitted claim dispute. Any additional documentation submitted to the resolution organization must be submitted to the adverse party at the same time.

(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. 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) The resolution organization may not communicate ex parte either with the health plan or the provider during the dispute resolution.

(e) The resolution organization shall issue a written recommendation, including findings of fact relating to the calculation under Section 641.513 (5), F.S., for the recommended amount due for the disputed claim, including any evidence relied upon.

(f) The resolution organization shall issue a written recommendation, which includes findings of fact, to the Agency within 60 days after the requested information is received by the resolution organization within the timeframes specified by the resolution organization. In no event shall the review time exceed 90 days following receipt of the initial claim dispute submission by the resolution organization.

(g) Within 30 days after receipt of the recommendations issued by the resolution organization the Agency shall adopt the recommendation as a final order.

(h) The final order is subject to judicial review pursuant to Section 120.68, F.S.

Rulemaking Authority 408.7057, 409.961 FS. Law Implemented 408.7057, 409.967 FS. History–New 10-23-00, Amended 3-28-01, 11-11-02, 8-10-17.