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The Department of Financial Services (DFS) reviews alleged prompt pay claim payment violations pursuant to s. 627.6131 and 641.3155, Florida Statutes. A summary of the timelines insurance companies and Health Maintenance Organizations (HMO) are required to meet is available under "Additional Information". Claims not paid or denied by the insurance company or HMO in accordance with Florida regulations should be submitted with written documentation indicating the claims were received by the health plan.

If it is determined that your claims fall within the regulatory authority of the DFS, you will be requested to submit up to five of your outstanding claims for each company. If necessary, we will request additional claims or documentation from you.

Under s. 408.7057, Florida Statutes, claims which involve a dispute regarding whether payment should be made or the amount of a payment, should be referred to the Statewide Provider and Health Plan Claim Dispute Resolution Program (Maximus). The Agency for Health Care Administration (AHCA) contracts with Maximus to administer this dispute resolution program. You may obtain information regarding the claim dispute resolution process by calling Maximus toll free at 1-866-763-6395.

The DFS does not have authority over the following contracts:

  1. Contracts purchased in a state other than Florida. If the contract was purchased in a state other than Florida, you should contact that state’s Department of Insurance. You can access the appropriate state’s contact information on the National Association of Insurance Commissioners’ website at http://www.naic.org/state_web_map.htm,

  2. Self-insured federal government employee contracts,

  3. Self-insured Employee Welfare Benefit Plans established under the Employee Retirement Income Security Act (ERISA), and

  4. Prepaid Dental claims (contractual).

 Additional Information:

Federal Agencies Who Handle Health Insurance Disputes

Disputes involving self-insured non-governmental plans should be referred to:

U.S. Department of Labor (USDOL)
Employee Benefit Security Administration
1000 S. Pine Island Road, Suite 100
Plantation, FL 33324
Toll Free Helpline: 1-866-444-3272

NOTE: The USDOL requires claim payment complaints to be filed by the patient/insured or his/her legal representative.

Disputes involving federal employee health benefit plans should be referred to:

U.S. Office of Personnel Management
Federal Employee Health Benefit Programs
1900 E. Street NW, Room 3443
Washington, DC 20415-0001
Telephone Number: (202) 606-0727

Disputes involving Tricare (military) claims should be referred to:

Palmetto Government Benefits Administration
Tricare Claims Department
PO Box 7031
Camden, SC 29021-7031
Toll Free Number: 1-800-403-3950
www.mytricare.com

Processing Provider Claims in a Timely Manner

Below is the summary of timeframes health insurers and Health Maintenance Organizations (HMO) must follow to pay and/or address claims in a timely manner pursuant to s. 627.6131 and 641.3155, Florida Statutes, respectively. The Department can review the claim(s) for compliance if the insurer or HMO has exceeded these time periods.

All Electronically Submitted Claims

  • A health insurer or HMO must acknowledge receipt of an electronically-filed claim within 24 hours after receipt of the claim.

  • A health insurer or HMO must pay or notify the provider or designee if a claim is denied or contested within 20 days after receipt of the claim.

  • A provider must submit additional information regarding the denied or contested claim within 35 days after receipt of the notification.

  • An insurer or HMO must pay or deny a claim within 90 days after receipt of the claim. Failure to pay or deny a claim within 120 days after receipt creates an uncontestable obligation to pay the claim.

Non-electronically Submitted Claims

  • A health insurer or HMO must acknowledge receipt of a claim within 15 days after receipt of the claim.

  • Within 40 days after receipt of the claim, a health insurer or HMO must pay the claim or notify a provider or designee if a claim is denied or contested.

  • A provider must submit additional information or documentation within 35 days after receipt of the notification.

  • 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 creates an uncontestable obligation to pay the claim.

An overdue payment of a claim bears simple interest of 12% per year. Proof of receipt of the claim(s) by the insurance company or HMO must be provided when filing with our office.