945.604 Medical claims.

FLORIDA STATUTES AND CODES

(1) DEFINITION OF “CLAIM.” As used in this section, for a noninstitutional health care provider the term “claim” means a paper or electronic billing instrument submitted to the department which consists of the HCFA 1500 data set, or its successor, and has all mandatory entries for a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463 or a psychologist licensed under chapter 490, or any appropriate billing instrument that has all mandatory entries for any other noninstitutional health care provider. For an institutional health care provider, the term “claim” means a paper or electronic billing instrument submitted to the department which consists of the UB-92 data set, or its successor, with entries stated as mandatory by the National Uniform Billing Committee.

(2) SUBMISSION DATE. Claims for payment or underpayment are considered submitted on the date the claim for payment is mailed or electronically transferred to the department by the health care provider. Claims for overpayment are considered submitted on the date the claim for overpayment is mailed or electronically transferred to the health care provider by the department.

(3) CLAIMS FOR PAYMENT OR UNDERPAYMENT.

(a) Claims for payment or underpayment must be submitted to the department within 6 months after the following have occurred:

1. The discharge of the inmate for inpatient services rendered to the inmate or the date of service for outpatient services rendered to the inmate; and

2. The health care provider has been furnished with the correct name and address of the department.

(b) Claims for payment or underpayment must not duplicate a claim previously submitted unless it is determined the original claim was not received or is otherwise lost.

(c) The department is not obligated to pay claims for payment or underpayment which were not submitted in accordance with paragraph (a).

(4) CLAIMS FOR OVERPAYMENT.

(a) If the department determines that it has made an overpayment to a health care provider for services rendered to an inmate, it must make a claim for such overpayment to the provider’s designated location. The department shall provide a written or electronic statement specifying the basis for overpayment. The department must identify the claim or claims, or overpayment claim portion thereof, for which a claim for overpayment is submitted.

(b) The department must submit a claim for overpayment to a health care provider within 30 months after the department’s payment of the claim, except that claims for overpayment may be submitted beyond that time from providers convicted of fraud pursuant to s. 817.234.

(c) Health care providers are not obligated to pay claims for overpayment which were not submitted in accordance with paragraph (b).

(d) A health care provider must pay, deny, or contest the department’s claim for overpayment within 40 days after the receipt of the claim for overpayment.

(e) A health care provider that denies or contests the department’s claim for overpayment or any portion of a claim shall notify the department, in writing, within 40 days after the provider receives the claim. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information.

(f) All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny the claim for overpayment within 140 days after receipt creates an uncontestable obligation to pay the claim.

(g) The department may not reduce payment to the health care provider for other services unless the provider agrees to the reduction or fails to respond to the department’s claim for overpayment as required by this subsection.

(5) NONWAIVER OF PROVISIONS. The provisions of this section may not be waived, voided, or nullified by contract.

History. s. 7, ch. 2009-63.