Florida legislation · 2026 Regular Session
Florida S1130: Insurance Claims Payments to Health Care Providers
Status: Failed, March 13, 2026
Prohibiting payment adjudicators from downcoding health care services under certain circumstances; specifying that payment adjudicators are solely responsible for certain violations of law; requiring certain utilization review entities to only use a certain prior authorization form; revising the definition of the term "claim", etc.
What the bill says
An act relating to insurance claims payments to health care providers; creating s. 627.4193, F.S.; defining terms; prohibiting payment adjudicators from downcoding health care services under certain circumstances; providing exceptions; requiring payment adjudicators to provide certain information to the provider; prohibiting payment adjudicators from downcoding a service under certain circumstances; prohibiting payment adjudicators for downcoding orders by a licensed nurse; specifying that payment adjudicators are solely responsible for certain violations of law…
From the introduced text, January 5, 2026:
A bill to be entitled An act relating to insurance claims payments to health care providers; creating s. 627.4193, F.S.; defining terms; prohibiting payment adjudicators from downcoding health care services under certain circumstances; providing exceptions; requiring payment adjudicators to provide certain information to the provider; prohibiting payment adjudicators from downcoding a service under certain circumstances; prohibiting payment adjudicators for downcoding orders by a licensed nurse; specifying that payment adjudicators are solely responsible for certain violations of law; requiring payment adjudicators to maintain downcoding policies on their websites; specifying requirements for such policies; requiring health insurers to ensure that their downcoding policies are updated and to ensure compliance with specified provisions on downcoding; authorizing investigations and actions against noncompliance; providing certain presumption in favor of physicians' determinations regarding diagnoses of patients and service orders; providing the calculation of interest on health insurers' nonpayment or underpayment due to downcoding; providing a cause of action for health care providers; amending s. 627.42392, F.S.; defining terms; revising the definition of the term "health insurer"; requiring certain utilization review entities to only use a certain prior authorization form; deleting provisions related to pharmacy benefits managers' or health insurers' requirement to use a specified prior authorization form; requiring utilization review entities to establish and offer a specified electronic prior authorization process; specifying requirements for such process; …