Fla. Stat. § 636.035 — Florida Code / Title XXXVII / Chapter 636 / Part I / Section 636.035
636.035 Provider arrangements.
Status: in_force

(1) Whenever a contract exists between a prepaid limited health service organization and a provider, and the organization fails to meet its obligations to pay fees for services already rendered to a subscriber who is in good standing, the prepaid limited health service organization is liable for such fee or fees rather than the subscriber, and the contract must so state.

(2) No subscriber, who is in good standing, of a prepaid limited health service organization is liable to any provider of health care services for any services covered by the prepaid limited health service organization.

(3) No provider of prepaid limited health care services or any representative of such provider may collect or attempt to collect from a subscriber any money for services covered by a prepaid limited health service organization, and no provider or representative of such provider may maintain any action against a subscriber of a prepaid limited health service organization to collect money owed to such provider by a prepaid limited health service organization.

(4) Every contract between a prepaid limited health service 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 covered by the subscriber’s or enrollee’s contract with the prepaid limited health service organization.

(5) The provisions of this section do not apply to the amount of any deductible or copayment which is not covered by the contract, or for services not authorized by the prepaid limited health service organization.

(6) For all provider contracts executed after October 1, 1993, and within 180 days after October 1, 1993, for contracts in existence as of October 1, 1993: (a) The contracts must provide that the provider will provide no less than 90 days’ advance written notice to the prepaid limited health service organization before canceling the contract with the prepaid limited health service organization for any reason. (b) The contract must also provide that nonpayment for goods or services rendered by the provider to the prepaid limited health service organization shall not be a valid reason for avoiding the 90-day advance notice of cancellation. (c) For all provider contracts in force on October 1, 1993, the organization shall be responsible for notifying all providers of the provisions of this section and their responsibilities under this part.

(7) Upon receipt by the prepaid limited health service organization of a 90-day cancellation notice, the prepaid limited health service organization may, if requested by the provider, terminate the contract in less than 90 days if the prepaid limited health service organization is not financially impaired or insolvent.

(8) Provider contracts executed after October 1, 1997, and within 180 days after October 1, 1997, for all contracts in existence on October 1, 1997, must provide that the prepaid limited health service organization will provide 90 days’ advance written notice to the provider before canceling, without cause, the contract with the provider, except where a patient’s health is subject to imminent danger or a provider’s ability to practice is effectively impaired by an action by the Board of Dentistry or another governmental agency.

(9) Every contract between a prepaid limited health service organization and a provider of health care services must contain a provision that if any provision of the agreement is held to be unenforceable or otherwise contrary to any applicable laws, regulations, or rules, such provision shall have no effect and shall be severable without affecting the validity or enforceability of the remaining provisions of this agreement. This subsection applies to policies issued or renewed after October 1, 1997.

(10) A contract between a prepaid limited health service organization and a provider of limited health care services may not contain any provision restricting the provider’s ability to communicate information to the provider’s patient regarding 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.

(11) A contract between a prepaid limited health service organization and a provider of limited health services may not contain any provision that in any way prohibits or restricts the limited health service provider from entering into or renewing a contract with any other prepaid limited health service organization. This subsection applies to all contracts entered into or renewed on or after July 1, 2009.

(12) A prepaid limited health service organization may not require, as a condition of continuation or renewal of a contract, a contracted limited health service provider to accept the terms of other health care practitioner contracts with the prepaid limited health service organization or any insurer or other limited health service organization under common management and control with the prepaid limited health service organization, including, but not limited to, Medicare and Medicaid practitioner contracts and those authorized by s. 627.6471, s. 627.6472, s. 641.315, 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. Any contract provision that violates this subsection is void. A violation of this subsection is not subject to the criminal penalty specified in s. 624.15. This subsection applies to all contracts entered into or renewed on or after July 1, 2009.

(13) A contract between a prepaid limited health service organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the prepaid limited health service organization may not contain a provision that requires the dentist to provide services to the subscriber of the prepaid limited health service organization at a fee set by the prepaid limited health service 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.

(14)(a) A prepaid limited health service 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 prepaid limited health service 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 prepaid limited health service 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).

(15)(a) A prepaid limited health service 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 dental service 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 prepaid limited health service 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.

History: s. 28, ch. 93-148; s. 3, ch. 97-65; s. 2, ch. 2009-41; s. 2, ch. 2014-64; s. 2, ch. 2016-69; s. 3, ch. 2024-196.