Florida HB 1015: Insurance Claims Payments to Health Care Providers

Bill Text

HB 1015 2026

CODING: Words stricken are deletions; words underlined are additions.
hb1015-00
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A bill to be entitled 1
An act relating to insurance claims payments to health 2
care providers; creating s. 627.4193, F.S.; providing 3
definitions; prohibiting payment adjudicators from 4
downcoding health care services under certain 5
circumstances; providing exceptions; providing 6
requirements for such exceptions; requiring health 7
insurers to ensure that their downcoding policies are 8
updated and to ensure compliance with specified 9
provisions on downcoding; authorizing investigations 10
and actions against noncompliance; providing certain 11
presumption in favor of physicians' determination 12
regarding patients' diagnoses and service orders; 13
providing calculations of interests on health 14
insurers' nonpayment and underpayment due to 15
downcoding; providing causes of action for health care 16
providers; amending s. 627.42392, F.S.; providing and 17
revising definitions; requiring utilization review 18
entities to establish electronic prior authorizations 19
to accept prior authorization requests; providing 20
requirements for such entities and for prior 21
authorization processes; prohibiting such entities 22
from implementing new requirements, restrictions, and 23
changes; providing exceptions; providing reporting 24
requirements; requiring the Office of Insurance 25

HB 1015 2026

CODING: Words stricken are deletions; words underlined are additions.
hb1015-00
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S

Regulation to publish a report based on such entities' 26
reports; providing requirements for adverse 27
determinations made by such entities on health care 28
providers' claims; providing a timeframe for such 29
entities' determination on claims; prohibiting prior 30
authorization requirements under certain 31
circumstances; prohibiting prior authorization 32
revocations, limits, conditions, and restrictions 33
under certain circumstances; providing exceptions; 34
providing validity timeframe of prior authorizations 35
under certain circumstances; providing construction; 36
amending ss. 627.6131 and 641.3155, F.S.; providing 37
and revising definitions; revising requirements and 38
timeframes for responses from health insurers and 39
health maintenance organizations, respectively, to 40
submitted claims; revising interests on overdue 41
payments of claims; authorizing health care providers 42
to refuse to participate in internal dispute 43
resolution processes under certain circumstances; 44
prohibiting health insurers and health maintenance 45
organizations, respectively, from retrospectively, 46
rather than retroactively, denying claims because of 47
insured and enrollee ineligibility beyond a specified 48
timeframe; revising such timeframe; revising 49
applicability; providing construction; prohibiting 50

HB 1015 2026

CODING: Words stricken are deletions; words underlined are additions.
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S

health insurers and health maintenance organizations, 51
respectively, from requesting or requiring certain 52
information from health care providers under certain 53
circumstances; providing causes of action for health 54
care providers under certain circumstances; amending 55
s. 395.1065, F.S.; conforming cross-references; 56
providing an effective date. 57
58
Be It Enacted by the Legislature of the State of Florida: 59
60
Section 1. Section 627.4193, Florida Statutes, is created 61
to read: 62
627.4193 Restrictions on health insurance reimbursement 63
downcoding.— 64
(1) As used in this section, the term: 65
(a) "Downcode" or "downcoding" means the alteration by a 66
payment adjudicator of a service code to another service code or 67
the alteration, addition, or removal by a payment adjudicator of 68
a modifier, when the changed code or modifier is associated with 69
a lower payment amount than the service code or modifier billed 70
by the provider or facility. 71
(b) "Health insurer" means any entity that offers health 72
insurance coverage, whether through a fully insured plan or 73
self-insured plan or fund, including, as applicable: 74
1. An authorized health insurer offering health insurance 75

HB 1015 2026

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as defined in s. 624.603, as well as any entity that offers a 76
commercial self-insurance fund as defined in s. 624.462(2) or 77
group self-insurance fund as described in s. 624.4621. 78
2. A health insurer that is subject to any of the 79
provisions of this chapter, as well as any entity that offers a 80
self-insurance plan or a group self-insurance plan. 81
3. A managed care plan as defined in s. 409.962. 82
4. A health maintenance organization as defined in s. 83
641.