Processing Provider Claims in a Timely Manner

Below is the summary of time frames health insurance companies and Health Maintenance Organizations (HMOs) must follow to pay and/or address claims in a timely manner, pursuant to Florida Statute Chapters 627.6131 and 641.3155. If the medical provider claims are not being handled according to this timeline, the Florida Department of Financial Services can review your claim(s) for compliance.

All Electronically Submitted Claims

• A health insurer must acknowledge receipt of an electronic filed claim within 24 hours after receipt of the claim.

 

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

 

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

 

• An insurer 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 of claim creates an uncontestable obligation to pay the claim.

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Non-electronically Submitted Claims

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

 

• Within 40 days after receipt of the claim, a health insurer 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.