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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 the provisions of this section, the office may fine a health maintenance organization for claims payment violations of paragraphs (3)(e) and (4)(e) which create an uncontestable obligation to pay the claim.

Except in cases in which the health care provider is an employee of the health maintenance organization, the fact that the health maintenance organization arranges for the provision of health care services under this chapter does not create an actual agency, apparent agency, or employer-employee relationship between the health care provider and the health maintenance organization for purposes of vicarious liability for the medical negligence of the health care provider.“Insolvent” or “insolvency” means that all the statutory assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities or that the health maintenance organization is unable to pay its debts as they become due in the usual course of business. The office shall not fine organizations for violations which the office determines were due to circumstances beyond the organization’s control.

641.31074; provide notice of cancellation pursuant to s. The interest is payable with the payment of the claim.

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 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.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. Payment of an overpayment 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 at the rate of 12 percent per year.Through these organizations, structured in various forms, health care services are provided directly to a group of people who make regular premium payments. An audited financial statement prepared on the basis of statutory accounting principles and certified by an independent certified public accountant, except that surplus notes acceptable to the office and meeting the requirements of this act shall be included in the calculation of surplus; and Such additional reasonable data, financial statements, and other pertinent information as the commission or office requires with respect to the determination that the applicant can provide the services to be offered. This subsection does not affect the applicability of ss. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim.Although it is the intent of this act to provide an opportunity for the development of health maintenance organizations, there is no intent to impair the present system for the delivery of health services. After submission of the application for a certificate of authority, the entity may engage in initial group marketing activities solely with respect to employers, representatives of labor unions, professional associations, and trade associations, so long as it does not enter into, issue, deliver, or otherwise effectuate health maintenance contracts, effectuate or bind coverage or benefits, provide health care services, or collect premiums or charges until it has been issued a certificate of authority by the office. 641.3154 and 641.513 with respect to services provided and payment for such services provided pursuant to the subsection. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.

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