Florida Statute 641.3155 - Full Text and Legal Analysis

The 2025 Florida Statutes

Title XXXVII
INSURANCE

Chapter 641
HEALTH CARE SERVICE PROGRAMS

View Entire Chapter

641.3155 Prompt payment of claims.—

(1) As used in this section, the term “claim” for a noninstitutional provider means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the HCFA 1500 data set, or its successor, that has all mandatory entries for a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463, or psychologists licensed under chapter 490 or any appropriate billing instrument that has all mandatory entries for any other noninstitutional provider. For institutional providers, “claim” means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the UB-92 data set or its successor with entries stated as mandatory by the National Uniform Billing Committee.

(2) All claims for payment or overpayment, whether electronic or nonelectronic:

(a) Are considered received on the date the claim is received by the organization at its designated claims-receipt location or the date a claim for overpayment is received by the provider at its designated location.

(b) Must be mailed or electronically transferred to the primary organization within 6 months after the following have occurred:

1. Discharge for inpatient services or the date of service for outpatient services; and

2. The provider has been furnished with the correct name and address of the patient’s health maintenance organization.

All claims for payment, whether electronic or nonelectronic, must be mailed or electronically transferred to the secondary organization within 90 days after final determination by the primary organization. A provider’s claim is considered submitted on the date it is electronically transferred or mailed.

(c) Must not duplicate a claim previously submitted unless it is determined that the original claim was not received or is otherwise lost.

(3) For all electronically submitted claims, a health maintenance organization shall:

(a) Within 24 hours after the beginning of the next business day after receipt of the claim, provide electronic acknowledgment of the receipt of the claim to the electronic source submitting the claim.

(b) Within 20 days after receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the organization’s action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

(c)1. Notification of the health maintenance organization’s determination of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim.

2. A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health maintenance organization may not request duplicate documents.

(d) For purposes of this subsection, electronic means of transmission of claims, notices, documents, forms, and payment shall be used to the greatest extent possible by the health maintenance organization and the provider.

(e) A claim must be paid or denied within 90 days after receipt of the claim. Failure to pay or deny a claim within 120 days after receipt of the claim creates an uncontestable obligation to pay the claim.

(4) For all nonelectronically submitted claims, a health maintenance organization shall:

(a) Effective November 1, 2003, provide acknowledgment of receipt of the claim within 15 days after receipt of the claim to the provider or designee or provide a provider or designee within 15 days after receipt with electronic access to the status of a submitted claim.

(b) Within 40 days after receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the health maintenance organization’s action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

(c)1. Notification of the health maintenance organization’s determination of a contested claim must be accompanied by an itemized list of additional information or documents the organization can reasonably determine are necessary to process the claim.

(d) For purposes of this subsection, electronic means of transmission of claims, notices, documents, forms, and payments shall be used to the greatest extent possible by the health maintenance organization and the provider.

(e) A claim must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny a claim within 140 days after receipt of the claim creates an uncontestable obligation to pay the claim.

(5) If a health maintenance organization determines that it has made an overpayment to a provider for services rendered to a subscriber, the health maintenance organization must make a claim for such overpayment to the provider’s designated location. A health maintenance organization that makes a claim for overpayment to a provider under this section shall give the provider a written or electronic statement specifying the basis for the retroactive denial or payment adjustment. The health maintenance organization must identify the claim or claims, or overpayment claim portion thereof, for which a claim for overpayment is submitted.

(a) If an overpayment determination is the result of retroactive review or audit of coverage decisions or payment levels not related to fraud, a health maintenance organization shall adhere to the following procedures:

1. All claims for overpayment must be submitted to a provider within 30 months after the health maintenance organization’s payment of the claim. A provider must pay, deny, or contest the health maintenance organization’s claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.

2. A provider that denies or contests a health maintenance organization’s claim for overpayment or any portion of a claim shall notify the organization, in writing, within 35 days after the provider receives the claim that the claim for overpayment is contested or denied. 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. If the organization submits additional information, the organization must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider. The provider shall pay or deny the claim for overpayment within 45 days after receipt of the information. The notice is considered made on the date the notice is mailed or electronically transferred by the provider.

3. The health maintenance organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization’s overpayment claim as required by this paragraph.

4. Payment of an overpayment claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest at the rate of 12 percent per year. Interest on an overdue payment for a claim for an overpayment payment begins to accrue when the claim should have been paid, denied, or contested.

(b) A claim for overpayment shall not be permitted beyond 30 months after the health maintenance organization’s payment of a claim, except that claims for overpayment may be sought beyond that time from providers convicted of fraud pursuant to s. 817.234.

(6) Payment of a claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest of 12 percent per year. Interest on an overdue payment for a claim or for any portion of a claim begins to accrue when the claim should have been paid, denied, or contested. The interest is payable with the payment of the claim.

(7) For all contracts entered into or renewed on or after October 1, 2002, a health maintenance organization’s internal dispute resolution process related to a denied claim not under active review by a mediator, arbitrator, or third-party dispute entity must be finalized within 60 days after the receipt of the provider’s request for review or appeal.

(8) A provider or any representative of a provider, regardless of whether the provider is under contract with the health maintenance organization, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency a subscriber for payment of covered services for which the health maintenance organization contested or denied the provider’s claim. This prohibition applies during the pendency of any claim for payment made by the provider to the health maintenance organization for payment of the services or internal dispute resolution process to determine whether the health maintenance organization is liable for the services. For a claim, this pendency applies from the date the claim or a portion of the claim is denied to the date of the completion of the health maintenance organization’s internal dispute resolution process, not to exceed 60 days. This subsection does not prohibit collection by the provider of copayments, coinsurance, or deductible amounts due the provider.

(9) The provisions of this section may not be waived, voided, or nullified by contract.

(10) A health maintenance organization may not retroactively deny a claim because of subscriber ineligibility more than 1 year after the date of payment of the claim.

(11) A health maintenance organization shall pay a contracted primary care or admitting physician, pursuant to such physician’s contract, for providing inpatient services in a contracted hospital to a subscriber if such services are determined by the health maintenance organization to be medically necessary and covered services under the health maintenance organization’s contract with the contract holder.

(12) A permissible error ratio of 5 percent is established for health maintenance organizations’ claims payment violations of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c), and (e). If the error ratio of a particular insurer does not exceed the permissible error ratio of 5 percent for an audit period, no fine shall be assessed for the noted claims violations for the audit period. The error ratio shall be determined by dividing the number of claims with violations found on a statistically valid sample of claims for the audit period by the total number of claims in the sample. If the error ratio exceeds the permissible error ratio of 5 percent, a fine may be assessed according to s. 624.4211 for those claims payment violations which exceed the error ratio. Notwithstanding the provisions of this section, the office may fine a health maintenance organization for claims payment violations of paragraphs (3)(e) and (4)(e) which create an uncontestable obligation to pay the claim. The office shall not fine organizations for violations which the office determines were due to circumstances beyond the organization’s control.

(13) This section shall apply to all claims or any portion of a claim submitted by a health maintenance organization subscriber under a health maintenance organization subscriber contract to the organization for payment.

(14) Notwithstanding paragraph (3)(b), where an electronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health maintenance organization, the pharmacy benefits manager shall, within 30 days of receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the organization’s action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

(15) Notwithstanding paragraph (4)(a), effective November 1, 2003, where a nonelectronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health maintenance organization, the pharmacy benefits manager shall provide acknowledgment of receipt of the claim within 30 days after receipt of the claim to the provider or provide a provider within 30 days after receipt with electronic access to the status of a submitted claim.

¹(16) Notwithstanding the 30-month period provided in subsection (5), all claims for overpayment submitted to a provider licensed under chapter 458, chapter 459, chapter 460, chapter 461, chapter 466, or chapter 490 must be submitted to the provider within 12 months after the health maintenance organization’s payment of the claim. A claim for overpayment may not be permitted beyond 12 months after the health maintenance organization’s payment of a claim, except that claims for overpayment may be sought beyond that time from providers convicted of fraud pursuant to s. 817.234.

(17) Notwithstanding any other provision of this section, all claims for underpayment from a provider licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466 must be submitted to the health maintenance organization within 12 months after the health maintenance organization’s payment of the claim. A claim for underpayment may not be permitted beyond 12 months after the health maintenance organization’s payment of a claim.

History.—s. 1, ch. 98-79; s. 5, ch. 99-393; s. 3, ch. 2000-252; s. 25, ch. 2000-256; s. 12, ch. 2002-389; s. 1584, ch. 2003-261; s. 8, ch. 2008-212; s. 155, ch. 2020-2; s. 2, ch. 2025-45.

¹Note.—Section 3, ch. 2025-45, provides that “[t]he amendments made by this act to ss. 627.6131(18) and 641.3155(16), Florida Statutes, apply to claims for services provided on or after January 1, 2026.”

F.S. 641.3155 on Google Scholar

F.S. 641.3155 on CourtListener

Amendments to 641.3155

Annotations, Discussions, Cases:

Cases Citing Statute 641.3155

Total Results: 11 | Sort by: Relevance | Newest First

Copy

Found. Health v. WESTSIDE EKG ASSOC., 944 So. 2d 188 (Fla. 2006).

Cited 23 times | Published | Supreme Court of Florida

...e. A medical service provider may bring a cause of action as a third-party beneficiary to the contract between the health maintenance organization and its subscriber based on allegations that the health maintenance organization failed to comply with section 641.3155, Florida Statutes (2001), the "prompt pay provisions" of the Health Maintenance Organization Act....

...rance/health maintenance policies." Westside claimed it was a third-party beneficiary to "such insurance/health maintenance contracts," and "[d]espite repeated demands," the defendant-HMOs had breached this contract by, among other things, violating section 641.3155, Florida Statutes (2001), the "prompt pay provisions" of Florida's Health Maintenance Organization Act ("HMO Act"), and sections 641.17-641.3923, Florida Statutes (2001)....

...[3] "As a direct and proximate result of such Breach of the Third Party Beneficiary Contracts," Westside claimed it "suffered damages in the amount of outstanding balances for its charges for services, together with interest and reasonable attorneys fees and costs." Section 641.3155 provides a time frame in which HMOs must respond to and pay claims properly submitted by medical service providers. At the time Westside filed its complaint in 2001, the pertinent part of the statute read as follows: *192 641.3155 Payment of Claims....

...ian's contract, for 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. § 641.3155, Fla....

...In addition, this statute defined the term "clean *193 claim," [4] imposed nearly reciprocal obligations on providers to respond to an HMO's claim for overpayment, and required that the amount of overpayment be reconciled to specific claims unless the parties agree otherwise. § 641.3155(1), (5)-(6), Fla....

...Id. We agree with the Fourth District. As we explain below, medical service providers may bring a breach of contract action as a third-party beneficiary of the contract between the HMO and its subscriber based upon the HMO's failure to comply with section 641.3155, Florida Statutes (2001). ANALYSIS I. Framework for Review The question at issue requires us to interpret the HMO Act, particularly section 641.3155, its "prompt pay provisions;" *194 therefore, the standard of review is de novo....

...om establishing that the contracting parties had a "clear or manifest intent" to benefit Westside. We conclude that, given the significant statutory regulation surrounding HMO contracts and the integral role the "prompt pay provisions" play in them, section 641.3155 may be incorporated into the HMO contract....

...on. See A.R. Moyer, Inc. v. Graham, 285 So.2d 397, 402 (Fla.1973) ("Without viewing the [contract at issue], which is absent from the record, we are unable to speculate if a cause of action would exist."). As the Fourth District correctly concluded, section 641.3155 can be incorporated into the HMO contract....

...Such an incorporation supports the first and third elements of the claim. Moreover, there is no basis to conclude that Westside is precluded, as a matter of law, from establishing the second element because of its status as a nonparticipating provider. B. Statutory Incorporation As stated earlier, we conclude that section 641.3155 (the "prompt pay provisions") may be incorporated into an HMO contract for the purpose of establishing a breach of contract cause of action when the provider's claim is for a service the HMO is required to provide under either the HMO Act or the HMO contract at the time the claim is filed....

...1 (1983), for the proposition that "[a]lthough . . . HMOs are not (traditionally defined) insurance companies, . . . the same contract construction rules apply"). So treated, the principles of statutory incorporation permit the "prompt pay provisions" of section 641.3155 to be considered an implicit part of every HMO contract....

...ued in Florida" because the statute addressed *196 a subject that was present in every insurance dispute and because another provision of the Florida Insurance Code supported incorporating this statute). Admittedly, the HMO Act does not mandate that section 641.3155 be included in HMO contracts....

...In fact, "[a] claim for treatment may not be denied" in this situation, "unless the provider provided information to the [HMO] with the willful intention to misinform the [HMO]." § 641.3156(2). The details set forth in the "prompt payment provision," section 641.3155, provide essential substance to the HMO's liability for services rendered to its subscribers....

...Here, the statutory language recognizing that a civil cause of action may be brought to enforce the HMO contract is particularly persuasive. HMOs enter into these contracts "to provide an agreed-upon set of comprehensive health care services to subscribers in exchange for a prepaid [fee]." § 641.31(1). As stated earlier, section 641.3155 simply provides essential details of how the HMOs are to pay medical providers for these services....

...In light of this, it is difficult to see how any HMO could enter into such contracts without assuming that the "prompt payment provision" is implicit therein. Given the above, we conclude that unless the terms of the individual HMO contract or the HMO Act properly provides otherwise, section 641.3155 may be incorporated as a term in the HMO contract for the *197 purpose of alleging a breach of third-party beneficiary contract claim....

...ave done so in regard to any of Westside's claims. Furthermore, this excerpt also requires HMOs to pay "other person[s] as required by law," and under the HMO Act, even nonparticipating providers may be persons entitled to payment by law. See, e.g., § 641.3155(4) (recognizing that an HMO's failure to pay or deny "any claim no later than 120 days after receiving [it] ....

...ppler color flow interpretations, Holter twenty-four-hour interpretations, stress test physician supervision, and stress test interpretations. [3] Although Westside's count for breach of third-party beneficiary contract does not specifically mention section 641.3155, this count incorporated Westside's general allegations concerning the prompt pay provision of section 641.3155, alleging that the HMOs failed to make payment or contest payment within forty-five days. Westside specifically alleged violations of section 641.3155 as well as section 627.613, Florida Statutes (2001), in the other two counts of its amended complaint. Section 627.613 provides time periods in which health insurers must pay claims for medical services. It imposes requirements similar to section 641.3155; however, HMOs with a valid certificate of authority are excluded from the provisions of the Florida Insurance Code, unless expressly stated otherwise. See §§ 641.201, 641.30(2), Fla. Stat. [4] In essence, a "clean claim" is defined in section 641.3155(1), Florida Statutes (2001), as a claim submitted without any defect or impropriety and with the proper substantiating paperwork. This term does not appear in the current version of section 641.3155, as the statute now defines a "claim" as the appropriate paper or electronic billing instrument. § 641.3155(1), Fla. Stat. (2005). [5] Section 641.3155 has been amended numerous times since Westside filed its complaint in 2001....

Copy

Lutz v. Prot. Life Ins. Co., 951 So. 2d 884 (Fla. 4th DCA 2007).

Cited 10 times | Published | Florida 4th District Court of Appeal | 2007 Fla. App. LEXIS 41, 2007 WL 5768

...Co., 605 So.2d 911, 914 (Fla. 2d DCA 1992) (applying the general principle to determine the extent to which a chiropractor's services were covered under an insurance policy). In Westside, the court found that the "prompt pay provisions" found in Florida Statutes section 641.3155 may be incorporated into an HMO contract for the purpose of establishing a breach of contract cause of action when the provider's claim is for a service the HMO is required to provide either under the HMO Act or the HMO contract....

Copy

Westside EKG Assocs. v. Found. Health, 932 So. 2d 214 (Fla. 4th DCA 2005).

Cited 9 times | Published | Florida 4th District Court of Appeal | 2005 WL 1026183

...iation Act (Act), chapter 641, Florida Statutes, for the improper processing of providers' claims for medical services rendered to HMO subscribers. Westside claims HMOs failed to comply with the "prompt pay" provisions of the Act, primarily found in section 641.3155....

...Lissenden Co. v. Bd. of Cty. Comm'rs of Palm Beach, 116 So.2d 632 (Fla.1960); Citizens Ins. Co. v. Barnes, 98 Fla. 933, 124 So. 722 (1929). The Act requires that health maintenance organizations pay or deny a claim no later than 120 days after receipt. § 641.3155(2),(4), Fla. Stat. Failure to do so results in an uncontestable obligation that the health maintenance organization pay the claim to the health care provider. Id. See § 641.3155(4)....

...principles. Id. at 892; see also Orion Ins. Co. v. Magnetic Imaging Sys. I, 696 So.2d 475, 478 (Fla. 3d DCA 1997). Kaklamanos is significant, as the regulatory scheme for the Act is patterned after provisions in the Florida Insurance *220 Code. [3] Section 641.3155 contains provisions similar to those found in the PIP statute section 627.736(4), Florida Statutes. Section 641.3155(2)-(3) imposes deadlines for the HMO to contest or deny claims, to take other action, and obligates the HMO to pay interest on overdue payments....

...COURTS IN AN ACTION FOUNDED ON PRINCIPLES OF BREACH OF CONTRACT BROUGHT AGAINST A HMO BY A SERVICE PROVIDER? FARMER, C.J., and TAYLOR, J., concur. NOTES [1] When a HMO is liable for payment to a service provider based on an uncontestable claim under 641.3155(c), an administrative procedure is established under section 408.7056, Florida Statutes, of the Health Care Administration Act....

...Mekras, 679 So.2d 278 (Fla.1996)(medical malpractice statute). A person's guaranteed access to the courts should not be unduly or unreasonably burdened or restricted. Preferred Med. Plan, Inc. v. Ramos, 742 So.2d 322 (Fla. 3d DCA 1999). [3] See and compare: §§ 641.3155; 627.613; 627.614; 641.3104; 627.060; 641.31; 641.3101; 641.3106; 641.3917; 641.3107, Fla....

Copy

HEALTH OPTIONS v. Palmetto Pathology Servs., 983 So. 2d 608 (Fla. 3d DCA 2008).

Cited 8 times | Published | Florida 3rd District Court of Appeal | 2008 Fla. App. LEXIS 5506, 2008 WL 1733673

...[5] Employee Retirement Income Security Act of 1974. See 29 U.S.C. § 18. [6] In this case, HOI's member contracts are expressly subject to "all applicable state and federal laws and regulations." The contracts do not exclude either the "prompt pay" provision (section 641.3155) or subsection 641.3154(1), Florida Statutes (2005)....

Copy

Sheridan Healthcorp., Inc. v. Neighborhood Health P'ship, Inc., 459 F. Supp. 2d 1269 (S.D. Fla. 2006).

Cited 2 times | Published | District Court, S.D. Florida | 2006 U.S. Dist. LEXIS 76811, 2006 WL 3059883

...NOTES [1] Sheridan alleges that NHP's failure to pay Sheridan for services rendered to NHP members, in violation of Fla. Stat. § 641.3154, and NHP's failure to pay Sheridan's "clean claims" that were filed electronically within a 120-day period, violate Fla. Stat. § 641.3155(6)....

Copy

Found. Health v. Garcia-Rivera, 814 So. 2d 537 (Fla. 3d DCA 2002).

Cited 2 times | Published | Florida 3rd District Court of Appeal | 2002 WL 805029

...As in the meaningfully indistinguishable case of Colonial Penn Insurance Co. v. Magnetic Imaging Systems, I, Ltd., 694 So.2d 852 (Fla. 3d DCA 1997), the trial court properly certified a class of contract providers to the appellant HMOs in an action for the alleged violation of the "prompt pay" provisions of section 641.3155, Florida Statutes (1999)....

...3d DCA 1981), review denied, 417 So.2d 328 (Fla.1982), and is without substantive merit. See Burns v. Prudential Securities, Inc., 145 Ohio App.3d 424, 763 N.E.2d 234 (2001) (proper exercise of discretion to conclude that class action preferable to multiple individual arbitration proceedings). Affirmed. NOTES [1] 641.3155 Provider contracts; payment of claims....

Copy

Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 371 F. Supp. 3d 1056 (M.D. Fla. 2019).

Cited 2 times | Published | District Court, M.D. Florida

...2) In Count I, Plaintiff alleged that Defendant failed to pay the proper rate for health care claims in violation of Fla. Stat. § 641.513 (5). ( Id. at ¶¶ 24-34 ) In Count II, Plaintiff asserted that Defendant failed to make timely payments in violation of Fla. Stat. §§ 641.3155 and 627.6131....

...Florida Law Overview Florida law requires HMOs, such as Defendant, to reimburse out-of-network emergency medical service providers, such as Plaintiff, within certain time parameters and at specified rates for emergency services medical treatment. See Fla. Stat. §§ 641.513 (5), 641.3155(3), 627.6131(4)(b), and 627.64194....

...nity where the services were provided; or (c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days of the submittal of the claim. Fla. Stat. § 641.513 (5). Secondly, Plaintiff asserts its claims under § 641.3155, a provision of Florida's "Prompt Pay Act" mandating that HMOs must respond to and pay medical service provider claims in accordance with specified requirements. Fla. Stat. § 641.3155 . Specifically, § 641.3155(3)(b) states that "within 20 days after receipt of [an electronically submitted] claim" an HMO "shall ......

...e insurer can reasonably determine are necessary to process the claim. 2. A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Id. at (3)(c). Lastly, § 641.3155(4) establishes the time requirements for nonelectronically submitted claims....

...The third statute Plaintiff cites is § 627.6131, a section of the Florida Insurance Code imposing time and documentation requirements concerning the payment of health insurance claims. Fla. Stat. § 627.6131 . The language and requirements in the applicable provisions of this section are identical to the cited provisions of § 641.3155. compare id. at (4)-(5), with Fla. Stat. § 641.3155 (3) - (4). For example, § 627.61314 imposes the same requirement that is mandated under § 641.3155 for an insurer to pay or deny an electronically submitted claim "within 20 days." Fla....

...§ 627.6131 (4)(b). Additionally, § 627.6131 also similarly instructs that an insurer's failure to respond to a claim "within 120 days after receipt of the claim creates an uncontestable obligation to pay the claim." Id. at (4)(e). Subsection (4)(c) also echoes § 641.3155(3)(c) concerning the required documentation that must accompany any contested or denied claim. Id. at (4)(c). Likewise, § 627.6131(5) parrots § 641.3155(5)'s mandate concerning the procedure for nonelectronically submitted claims....

...n Plaintiff's capacity as a third party beneficiary. (Dkt. 2 at 1, 5-7) Accordingly, Plaintiff cannot rely on § 641.513 to establish an independent legal duty in the Pinellas County Cases. For the same reason, the remaining claims, asserted under §§ 641.3155 7 and 627.6131, must also be similarly construed under a third party beneficiary theory....

...3; (Dkt. 55); compare Hillsborough County First-Filed Case , Docket No. 2 at 5-10; with Premier Inpatient Partners, LLC, (D.A.Z.) , 8:19-cv-00242-MSS-AAS, Docket No. 1-1. Additionally, a review of the Florida HMO Act's "prompt pay" laws reveals that § 641.3155 does not expressly authorize a private cause of action to enforce its provisions....

...6:12-cv-100-Orl-22DAB, 2013 WL 12149554 , at *3, 2013 U.S. Dist. LEXIS 195495 , at *9 (M.D. Fla. Jan. 2, 2013) (quoting Found. Health v. Westside EKG Assocs. , 944 So.2d 188 , 190 (Fla. 2006) (internal quotation and citation omitted) ). Accordingly, under § 641.3155, medical service providers may only "bring a cause of action under the "prompt pay" laws as a third-party beneficiary to the contract between the [HMO] and its subscriber based on allegations that the HMO failed to comply with § 641.3155, Fla. Stat." Id. Consequently, even if asserted as direct actions, Plaintiff's claims under § 641.3155 are viable only under a third-party beneficiary theory and do not amount to an "independent" legal duty under Davila .

Copy

Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 362 F. Supp. 3d 1217 (M.D. Fla. 2019).

Cited 2 times | Published | District Court, M.D. Florida

...2 ) In Count I, Plaintiff alleges that Defendant failed to pay the proper rate for health care claims in violation of Fla. Stat. § 641.513 (5). ( Id. at ¶¶ 24-34 ) In Count II, Plaintiff asserts that Defendant failed to make timely payments in violation of Fla. Stat. §§ 641.3155 and 627.6131....

...half of CMS and CMS is the real party of interest in any litigation involving the administration of the program.") The Court notes that in the Hillsborough County Cases, Plaintiff cites four (4) Florida Statutes in each of the initial Complaints-(i) § 641.3155(6) ; (ii) § 627.6131(7) ; (iii) § 641.513(5) ; and (iv) § 627.64194....

Copy

Joseph L. Riley Anesthesia Assocs. v. Stein, 27 So. 3d 140 (Fla. 5th DCA 2010).

Published | Florida 5th District Court of Appeal | 2010 Fla. App. LEXIS 556, 2010 WL 322156

...TORPY, J., and LAMBERT, B., Associate Judge, concur. NOTES [1] The trial court consolidated the 52 cases brought by the subscriber appellees. [2] This subsection would not, of course, prohibit collection by the provider of co-payments, co-insurance or deductible amounts due the provider. See § 641.3155(8), Fla....

Copy

Inst. of Cardiovascular Excellence, PLLC v. Fla. Agency for Health Care Admin. (In re Inst. of Cardiovascular Excellence, PLLC), 589 B.R. 204 (Bankr. M.D. Fla. 2018).

Published | United States Bankruptcy Court, M.D. Florida

...Pursuant to the Provider Agreement, Debtor performed medical services on Medicaid recipients and AHCA was, in turn, obligated by the Provider Agreement to pay Debtor $294,736.25. Debtor alleges that AHCA has neither paid the claims nor notified Debtor of any denied or contested claim, as required by section 641.3155(3)(b), Florida Statutes....

...AHCA has not paid the monies owed to Debtor and has not "notified" Debtor of a "denied or contested claim within 20 days" thereof. AHCA's failure to pay or deny the claim has created an "uncontestable obligation" to pay the claim plus interest, under section 641.3155(3)(b), Florida Statutes....

Copy

Lower Florida Keys Health Sys., Inc. v. Beacon Health Plans, Inc., 946 So. 2d 85 (Fla. 3d DCA 2006).

Published | Florida 3rd District Court of Appeal | 2006 Fla. App. LEXIS 21561, 2006 WL 3782957

to other reconciliation methods and terms.... § 641.3155(4), Fla. Stat. (1999)(emphasis added). The setoffs

This Florida statute resource is curated by Graham W. Syfert, Esq., a Jacksonville, Florida personal injury and workers' compensation attorney. For legal consultation, call 904-383-7448.