Section 641.315 - [Effective 1/1/2025] Provider contracts(1) Each contract between a health maintenance organization and a provider of health care services must be in writing and must contain a provision that the subscriber is not liable to the provider for any services for which the health maintenance organization is liable as specified in s. 641.3154.(2)(a) For all provider contracts executed after October 1, 1991, and within 180 days after October 1, 1991, for contracts in existence as of October 1, 1991: 1. The contracts must require the provider to give 60 days' advance written notice to the health maintenance organization and the office before canceling the contract with the health maintenance organization for any reason; and2. The contract must also provide that nonpayment for goods or services rendered by the provider to the health maintenance organization is not a valid reason for avoiding the 60-day advance notice of cancellation.(b) All provider contracts must provide that the health maintenance organization will provide 60 days' advance written notice to the provider and the office before canceling, without cause, the contract with the provider, except in a case in which a patient's health is subject to imminent danger or a physician's ability to practice medicine is effectively impaired by an action by the Board of Medicine or other governmental agency.(3) Upon receipt by the health maintenance organization of a 60-day cancellation notice, the health maintenance organization may, if requested by the provider, terminate the contract in less than 60 days if the health maintenance organization is not financially impaired or insolvent.(4) Whenever a contract exists between a health maintenance organization and a provider, the health maintenance organization shall disclose to the provider: (a) The mailing address or electronic address where claims should be sent for processing.(b) The telephone number that a provider may call to have questions and concerns regarding claims addressed.(c) The address of any separate claims-processing centers for specific types of services.(d)1. The complete schedule of reimbursements for all the services for which a health maintenance organization and a provider have contracted and any changes in or deviations from the contracted schedule of reimbursements. The health maintenance organization may satisfy this requirement by: a. Providing the schedule of reimbursements or changes in or deviations from the schedule by electronic means to the provider; orb. Providing a written copy of the schedule of reimbursements or changes or deviations from the schedule if requested by the provider.2. The schedule of reimbursements is subject to the nondisclosure provisions of the contract, and the provider shall maintain the confidentiality of the schedule. For purposes of this paragraph, the term "provider" means a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466. A health maintenance organization shall provide to its contracted providers no less than 30 calendar days' prior written notice of any changes in the information required in this subsection.
(5) A contract between a health maintenance organization and a provider of health care services shall not contain any provision restricting the provider's ability to communicate information to the provider's patient regarding medical care or treatment options for the patient when the provider deems knowledge of such information by the patient to be in the best interest of the health of the patient.(6) A contract between a health maintenance organization and a provider of health care services may not contain any provision that in any way prohibits or restricts: (a) The health care provider from entering into a commercial contract with any other health maintenance organization; or(b) The health maintenance organization from entering into a commercial contract with any other health care provider.(7) A health maintenance organization or health care provider may not terminate a contract with a health care provider or health maintenance organization unless the party terminating the contract provides the terminated party with a written reason for the contract termination, which may include termination for business reasons of the terminating party. The reason provided in the notice required in this section or any other information relating to the reason for termination does not create any new administrative or civil action and may not be used as substantive evidence in any such action, but may be used for impeachment purposes. As used in this subsection, the term "health care provider" means a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461, or a dentist licensed under chapter 466.(8) The health maintenance organization must establish written procedures for a contract provider to request and the health maintenance organization to grant authorization for utilization of health care services. The health maintenance organization must give written notice to the contract provider prior to any change in these procedures.(9) A contract between a health maintenance organization and a contracted primary care or admitting physician may not contain any provision that prohibits such physician from providing inpatient services in a contracted hospital to a subscriber if such services are determined by the organization to be medically necessary and covered services under the organization's contract with the contract holder.(10) A health maintenance organization shall not require a contracted health care practitioner as defined in s. 456.001(4) to accept the terms of other health care practitioner contracts with the health maintenance organization or any insurer, or other health maintenance organization, under common management and control with the health maintenance organization, including Medicare and Medicaid practitioner contracts and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or this section, except for a practitioner in a group practice as defined in s. 456.053 who must accept the terms of a contract negotiated for the practitioner by the group, as a condition of continuation or renewal of the contract. Any contract provision that violates this section is void. A violation of this section is not subject to the criminal penalty specified in s. 624.15.(11) A contract between a health maintenance organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the health maintenance organization may not contain a provision that requires the dentist to provide services to the subscriber of the health maintenance organization at a fee set by the health maintenance organization unless such services are covered services under the applicable contract. As used in this subsection, the term "covered services" means dental care services for which a reimbursement is available under the subscriber's contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.(12)(a) A health maintenance organization may not require an ophthalmologist licensed pursuant to chapter 458 or chapter 459 or an optometrist licensed pursuant to chapter 463 to join a network solely for the purpose of credentialing the licensee for another organization's vision network. This paragraph does not prevent such organization from entering into a contract with another organization's vision care plan to use the vision network.(b) A health maintenance organization may not restrict an ophthalmologist licensed pursuant to chapter 458 or chapter 459, an optometrist licensed pursuant to chapter 463, or an optician licensed pursuant to part I of chapter 484 to specific suppliers of materials or optical laboratories. This paragraph does not restrict such organization in determining specific amounts of coverage or reimbursement for the use of network or out-of-network suppliers or laboratories.(c) A health maintenance organization's online vision care network provider directory must be updated monthly to reflect the vision care providers currently participating in the organization's network.(d) A knowing violation of paragraph (a) or paragraph (b) constitutes an unfair insurance trade practice under s. 626.9541(1)(d).(13)(a) A contract between a health maintenance organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the health maintenance organization may not specify credit card payment as the only acceptable method for payments from the health maintenance organization to the dentist.(b) When a health maintenance organization employs the method of claims payment to a dentist through electronic funds transfer, including, but not limited to, virtual credit card payment, the health maintenance organization shall notify the dentist as provided in this paragraph and obtain the dentist's consent before employing the electronic funds transfer. The dentist's consent described in this paragraph applies to the dentist's entire practice. For the purpose of this paragraph, the dentist's consent, which may be given through e-mail, must bear the signature of the dentist. Such signature includes an electronic or digital signature if the form of signature is recognized as a valid signature under applicable federal law or state contract law or an act that demonstrates express consent, including, but not limited to, checking a box indicating consent. The health maintenance organization or dentist may not require that a dentist's consent as described in this paragraph be made on a patient-by-patient basis. The notification provided by the health maintenance organization to the dentist must include all of the following:1. The fees, if any, that are associated with the electronic funds transfer.2. The available methods of payment of claims by the health maintenance organization, with clear instructions to the dentist on how to select an alternative payment method.(c) A health maintenance organization that pays a claim to a dentist through Automated Clearing House transfer may not charge a fee solely to transmit the payment to the dentist unless the dentist has consented to the fee.(d) This subsection applies to contracts delivered, issued, or renewed on or after January 1, 2025.(e) The office has all rights and powers to enforce this subsection as provided by s. 624.307.(f) The commission may adopt rules to implement this subsection.(14)(a) A health maintenance organization may not deny any claim subsequently submitted by a dentist licensed under chapter 466 for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied: 1. Benefit limitations, such as annual maximums and frequency limitations not applicable at the time of the prior authorization, are reached subsequent to issuance of the prior authorization.2. The documentation provided by the person submitting the claim fails to support the claim as originally authorized.3. Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care.4. Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition occurs such that the prior authorized procedure would at that time have required disapproval pursuant to the terms and conditions for coverage under the patient's plan in effect at the time the prior authorization was issued.5. The denial of the claim was due to one of the following:a. Another payor is responsible for payment.b. The dentist has already been paid for the procedures identified in the claim.c. The claim was submitted fraudulently, or the prior authorization was based in whole or material part on erroneous information provided to the health maintenance organization by the dentist, patient, or other person not related to the organization.d. The person receiving the procedure was not eligible to receive the procedure on the date of service.e. The services were provided during the grace period established under s. 627.608 or applicable federal regulations, and the dental insurer notified the provider that the patient was in the grace period when the provider requested eligibility or enrollment verification from the dental insurer, if such request was made.(b) This subsection applies to all contracts delivered, issued, or renewed on or after January 1, 2025.(c) The office has all rights and powers to enforce this subsection as provided by s. 624.307.(d) The commission may adopt rules to implement this subsection.ss. 795, 809(1st), ch. 82-243; s. 12, ch. 83-198; s. 17, ch. 88-388; ss. 125, 187, 188, ch. 91-108; s. 4, ch. 91-429; s.5, ch. 96-223; s.2, ch. 97-159; s.2, ch. 99-264; s.4, ch. 99-275; s.1, ch. 2000-252; s.24, ch. 2000-256; s.3, ch. 2001-107; s.1582, ch. 2003-261; s.2, ch. 2004-321; s.3, ch. 2009-41; s.3, ch. 2014-64; s.3, ch. 2016-69.Amended by 2024 Fla. Laws, ch. 196,s 4, eff. 1/1/2025.Amended by 2016 Fla. Laws, ch. 69, s 3, eff. 7/1/2016.Amended by 2014 Fla. Laws, ch. 64, s 3, eff. 7/1/2014.This section is set out more than once due to postponed, multiple, or conflicting amendments.