Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-158 - EXCHANGE OF MEDICAID DATA WITH INSURERS › Section 69O-158.004 - Insurers to Provide HRS with Certain Information; Reimbursement; Failure to Comply

Current through Reg. 50, No. 138; July 16, 2024
(1) Every health
				insurer shall, upon request of AHCA for any records or any information
				contained in such records, pertaining to the coverage of any individual under a
				health insurance policy or to the medical benefits paid by or claims made to
				any insurer pursuant to such policy, make all requested records and information
				available to AHCA when such individual is a recipient of medical assistance or
				is a person who is legally responsible for such a recipient.
(2) Information obtained pursuant to this
				rule and Rule 59G-7.0211, F.A.C., shall be
				exempt from Chapter 119, F.S. No official, agent, servant, or employee of
				either the Office or any insurer shall be permitted to make any use of the
				information furnished pursuant to this rule except for investigations and
				records made for the purposes of determining whether insurance or other
				benefits could be, have been or should have been claimed pursuant to an
				insurance policy or other agreement with respect to items of medical care and
				services received by a particular individual for which medical assistance has
				been provided by AHCA or would otherwise be provided by AHCA if not for the
				liability or an insurer.
(3) Within
				30 days from the date of receipt, insurers shall respond to a request by AHCA
				that the insurer enter into an information reporting agreement or contract with
				AHCA. Insurers shall enter into information reporting agreements or contracts
				with AHCA within 90 days from the date of the receipt of the request unless
				exempted pursuant to paragraph
				59G-7.0211(3)(d),
				F.A.C.
(4) Unless otherwise
				stipulated in its information reporting contract, an insurer shall furnish to
				AHCA all requested information within 30 days of the effective date of the
				contract.
(5) After furnishing the
				information as agreed, insurers may file with AHCA for reimbursement in the
				manner set forth in paragraph
				59G-7.0211(3)(g),
				F.A.C.
(6) Failure by any insurer
				to comply with these rules and related Florida Statutes may subject that
				insurer to administrative penalties as prescribed in the applicable provision
				of the Florida Insurance Code. After the Office has been notified, pursuant to
				paragraph 59G-7.0211(3)(l),
				F.A.C., that an insurer has not complied with AHCA's request, the Office shall
				immediately notify the offending insurer by certified mail that if the insurer
				is not in compliance within 30 days from the date of receipt of the certified
				letter, the Office may impose an administrative penalty in an amount not to
				exceed the statutory limit. Upon any subsequent failure of the insurer to
				timely respond to a request by AHCA, the Office may proceed to suspend or
				revoke the insurer's certificate of authority. The Office shall keep AHCA
				informed as to the status of such proceedings and any resulting agreement by
				the insurer to comply.
Rulemaking Authority 409.910, 624.308 FS. Law Implemented
					 409.910, 624.307(1), 624.420, 624.421, 624.4211, 624.424(9), 624.444, 624.445,
					 641.23, 641.25, 641.261, 641.411, 641.45, 641.452
					 FS.
New 11-14-89, Formerly 4-80.004,
					 4-158.004.