The Department of Financial Services (DFS) reviews health claim payment delays pursuant to Florida Statute Sections 627.6131 and 641.3155. A summary of the timeline insurance companies are required to meet is available under "Additional Information". Claims not paid or denied by the health insurance plan or Health Maintenance Organization (HMO) in accordance with the above Florida laws should be submitted to us with written proof the claims in question have been received by the insurance plan.
If it is determined that your concerns do fall within the regulatory authority of the Florida Department of Financial Services, you will be asked to submit up to five (5) of your outstanding claims (per company). If necessary, we will request additional claims from you.
Under Florida Statute 408.7057, claims that 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). Currently, the Agency for Health Care Administration has contracted with Maximus to administer this program. You may obtain information regarding their claim dispute resolution process by calling 1-866-763-6395.
The DFS does not have authority over the following contracts:
Contracts purchased in a State other than Florida; if the contract was purchased in a state other than Florida. You will need to contact that State Department of Insurance. For your convenience, we have provided the link to the National Association of Insurance Commissioner (NAIC),
Self-insured Federal Government employee contracts,
Self-insured Employee Welfare Benefit Plan established under the Employee Retirement Income Security Act (ERISA),
and, Prepaid Dental claims (contractual)
Disputes involving Self-insured Non-Governmental Plans should be referred to the:
U.S. Department of Labor
* Employee Benefit Security Administration
1000 S. Pine Island Road, Suite 100
Plantation, FL 33324
Toll Free Helpline: 1-866-275-7922 or Direct: 954-424-4022
* Note: As per the U.S. Department of Labor, complaints must be filed by the patient/insured or his/her legal representative.
Disputes involving Federal Employee Plans should be referred to the:
U.S. Office of Personnel Management
Federal Employee Health Benefit Programs
Insurance Review Division, #1
1900 E. Street NW
Washington, DC 20415-3500
Telephone Number: (202) 606-0727
Disputes involving Tricare (Military) Claims should be referred to the:
Palmetto Government Benefits Administration
Tricare Claims Department
PO Box 7031
Camden, SC 29020-7031
Toll Free Number: 1-800-403-3950 South Region or
Web site Address: www.mytricare.com
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.
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.
An overdue payment of a claim bears simple interest of 12 percent per year on claims. (Proof of receipt by the insurance carrier or HMO must be provided.)