641.3156
Treatment authorization; payment of claims.
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641.3156 Treatment authorization; payment of claims.—
(1) A health maintenance organization must pay any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized by a provider empowered by contract with the health maintenance organization to authorize or direct the patient’s utilization of health care services and which was also authorized in accordance with the health maintenance organization’s current and communicated procedures, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.
(2) A claim for treatment may not be denied if a provider follows the health maintenance organization’s authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.
(3) Emergency services are subject to the provisions of s. 641.513 and are not subject to the provisions of this section.
History.—s. 4, ch. 2000-252.
Notes of Decisions
Cited in 3
cases, 2001–2010 · leading case: Foundation Health v. WESTSIDE EKG ASSOC.
Foundation Health v. WESTSIDE EKG ASSOC. (2006)
“Section 641.3156(1) requires HMOs to pay "any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized" by an appropriate person and in an appropriate manner.”
In Re Managed Care Litigation (2001)
“procedure or provisions to contain health insurance costs or cost increases”); Fla. Stat. § 641.3156 (prohibiting arbitrary denial of claims), Tex.”
Joseph L. Riley Anesthesia Associates v. Stein (2010)
“Thus, according to JLR, because it did not follow the authorization procedures articulated by Florida Health Care, JLR was not in a contract position with the health maintenance organization, and section 641.3156 required Florida Health Care to pay whatever bill JLR sent them…”
— 641.3156(1) — 2 cases
Foundation Health v. WESTSIDE EKG ASSOC. (2006)
“Section 641.3156(1) requires HMOs to pay "any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized" by an appropriate person and in an appropriate manner.”
Joseph L. Riley Anesthesia Associates v. Stein (2010)
“Thus, according to JLR, because it did not follow the authorization procedures articulated by Florida Health Care, JLR was not in a contract position with the health maintenance organization, and section 641.3156 required Florida Health Care to pay whatever bill JLR sent them…”
— 641.3156(2) — 1 case
Foundation Health v. WESTSIDE EKG ASSOC. (2006)
“Section 641.3156(1) requires HMOs to pay "any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized" by an appropriate person and in an appropriate manner.”
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