Liquidating partnership with capital deficiency
In the event that all the assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities, but the organization has a written guarantee of the type and subject to the same provisions as outlined in s. Notwithstanding paragraph (4)(a), effective November 1, 2003, where a nonelectronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health maintenance organization, the pharmacy benefits manager shall provide acknowledgment of receipt of the claim within 30 days after receipt of the claim to the provider or provide a provider within 30 days after receipt with electronic access to the status of a submitted claim. Is a misrepresentation for the purpose of inducing, or tending to induce, the lapse, forfeiture, exchange, conversion, or surrender of any health maintenance contract or health insurance policy, or contract providing health insurance as defined in s. Misrepresents the benefits, nature, characteristics, uses, standard, quantity, quality, cost, rate, scope, source, or geographic origin or location of any goods or services available from or provided by, directly or indirectly, any health maintenance organization. 641.3901, and each shall have the powers and duties specified in ss. Whenever the department or office has reason to believe that any person, entity, or health maintenance organization has engaged, or is engaging, in this state in any unfair method of competition or any unfair or deceptive act or practice as defined in s.641.225, the organization shall not be considered insolvent unless it is unable to pay its debts as they become due in the usual course of business.“Schedule of reimbursements” means a schedule of fees to be paid by a health maintenance organization to a physician provider for reimbursement for specific services pursuant to the terms of a contract. Notwithstanding the 30-month period provided in subsection (5), all claims for overpayment submitted to a provider licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466 must be submitted to the provider within 12 months after the health maintenance organization’s payment of the claim. Knowingly making, publishing, disseminating, circulating, or placing before the public, or causing, directly or indirectly, to be made, published, disseminated, circulated, or placed before the public:an advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of the health maintenance organization which is untrue, deceptive, or misleading. 641.3903 or is operating a health maintenance organization without a certificate of authority as required by this part and that a proceeding by it in respect thereto would be to the interest of the public, the department or office shall conduct or cause to have conducted a hearing in accordance with chapter 120.641.31(1) and (4); the covered services, including those services, medical conditions, and provider types specified in ss. A permissible error ratio of 5 percent is established for health maintenance organizations’ claims payment violations of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c), and (e).641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 641.513; and where and in what manner services may be obtained pursuant to s. If the error ratio of a particular insurer does not exceed the permissible error ratio of 5 percent for an audit period, no fine shall be assessed for the noted claims violations for the audit period.641.3111; provide for conversion on termination of eligibility pursuant to s. This subsection does not prohibit collection by the provider of copayments, coinsurance, or deductible amounts due the provider.641.3921; and provide for conversion contracts and conditions pursuant to s. A health maintenance organization subscriber should receive timely and, if necessary, urgent grievances and appeals within the health maintenance organization pursuant to ss. A health maintenance organization subscriber shall be given written notice at least 30 days in advance of a rate change pursuant to s. In the case of a group member, there may be a contractual agreement with the health maintenance organization to have the employer provide the required notice to the individual members of the group pursuant to s. A health maintenance organization subscriber shall be given a copy of the applicable health maintenance contract, certificate, or member handbook specifying: all the provisions, disclosure, and limitations required pursuant to s. A health maintenance organization shall pay a contracted primary care or admitting physician, pursuant to such physician’s contract, for providing inpatient services in a contracted hospital to a subscriber if such services are determined by the health maintenance organization to be medically necessary and covered services under the health maintenance organization’s contract with the contract holder.
641.3108; provide extension of benefits pursuant to s. For a claim, this pendency applies from the date the claim or a portion of the claim is denied to the date of the completion of the health maintenance organization’s internal dispute resolution process, not to exceed 60 days. Each application for a certificate shall be on such form as the commission shall prescribe, shall be verified by the oath of two officers of the corporation and properly notarized, and shall be accompanied by the following: A list of the names, addresses, and official capacities with the organization of the persons who are to be responsible for the conduct of the affairs of the health maintenance organization, including all officers, directors, and owners of in excess of 5 percent of the common stock of the corporation. The health maintenance organization contract may not prohibit, and claims forms must provide an option for, the payment of benefits directly to a licensed hospital, ambulance provider, physician, or dentist for covered services provided, for services provided pursuant to s. A provider must pay, deny, or contest the health maintenance organization’s claim for overpayment within 40 days after the receipt of the claim. However, the office may not issue a certificate of authority to any applicant which does not possess a valid health care provider certificate issued by the agency. Whenever, in any health maintenance organization claim form, a subscriber specifically authorizes payment of benefits directly to any contracted hospital, ambulance provider, physician, or dentist, the health maintenance organization shall make such payment to the designated provider of such services if any benefits are due to the subscriber under the terms of the agreement between the subscriber and the health maintenance organization. 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 If an overpayment determination is the result of retroactive review or audit of coverage decisions or payment levels not related to fraud, a health maintenance organization shall adhere to the following procedures: All claims for overpayment must be submitted to a provider within 30 months after the health maintenance organization’s payment of the claim.641.31(12) and 641.513, and second opinions pursuant to s. A health maintenance organization subscriber should receive assurance that the health maintenance organization has been independently accredited by a national review organization pursuant to s. Notwithstanding paragraph (a), an alternate process used by a health maintenance organization which includes early refill dates, refill overrides, and access on the health maintenance organization’s public website to the terms and conditions of such a process is deemed to comply with the requirements of this subsection.s. A claim for overpayment shall not be permitted beyond 30 months after the health maintenance organization’s payment of a claim, except that claims for overpayment may be sought beyond that time from providers convicted of fraud pursuant to s. Payment of a claim is considered made on the date the payment was mailed or electronically transferred.
641.512, and is financially secure as determined by the state pursuant to ss. A health maintenance organization subscriber should receive timely, concise information regarding the health maintenance organization’s reimbursement to providers and services pursuant to ss. An overdue payment of a claim bears simple interest of 12 percent per year.
Each female subscriber may select as her primary physician an obstetrician/gynecologist who has agreed to serve as a primary physician and is in the health maintenance organization’s provider network. Notwithstanding paragraph (3)(b), where an electronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health maintenance organization, the pharmacy benefits manager shall, within 30 days of receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. As used in this section, the term “impaired” means that the health maintenance organization does not meet the requirements of s. No person, entity, or health maintenance organization shall engage in this state in any trade practice which is defined in this part as, or determined pursuant to s. In addition to the powers and duties set forth in s.