Florida Prior Authorization Law

Overview

Florida HB 1209 (2024) establishes prior authorization requirements for health plans. Standard requests must be decided within 7 calendar days; urgent requests within 72 hours. Denials require peer-to-peer review between the treating physician and the insurer's medical director. Written denials must include clinical rationale.

Key Requirements

1. Insurers must acknowledge prior authorization requests within 1 business day.
2. Standard requests must be decided within 7 calendar days of receipt of complete submission.
3. Urgent requests must be decided within 72 hours of receipt.
4. All denials require peer-to-peer discussion between treating physician and insurer physician.
5. Written denials must include clinical rationale, plan provisions, and appeal rights.

Penalties and Enforcement

AHCA enforces HB 1209 prior authorization violations with regulatory action. Failure to provide peer-to-peer review for denials may result in automatic approval. Plans with systematic timeline violations face fines and corrective action orders. Enforcement action often results in consumer restitution.

Appeals and Exceptions

Denied prior authorization requests can be appealed within 30 days. Expedited appeals are available for urgent requests. Peer-to-peer review is mandatory for all denials. If the insurer fails to provide peer-to-peer review, the prior authorization request may be deemed approved.

Interaction with Federal Law

Florida HB 1209 establishes state-specific prior authorization standards. Federal ERISA rules for self-funded plans are less protective. Peer-to-peer and timeline requirements exceed federal minimums in most instances.

Common Questions