Notes on payer behavior
Florida prompt-pay law: what payers owe your practice (2026)
Florida's prompt-pay statutes — §627.6131 for insurers, §641.3155 for HMOs — put clocks on every stage of claim handling by a Florida-regulated payer. The clocks are specific, they carry interest, and they end in an unusual place: a claim neither paid nor denied on time becomes an obligation the payer can no longer contest. Here is the working guide.
The three clocks
- 20 days. An electronically submitted clean claim must be paid, denied, or contested within 20 days.
- 90 days. The payer must pay or deny the claim within 90 days of receipt.
- 120 days. Failure to pay or deny within 120 days creates an uncontestable obligation to pay. The payer's window to argue the claim is over.
Overdue clean claims accrue 12% simple interest; under the HMO statute the interest runs from day 36. The point of the interest provision is not the dollars on one claim — it is that a demand letter that computes interest from the statutory date reads as written by someone who knows the statute.
The supporting provisions
- Internal dispute resolution within 60 days. For contracts issued on or after October 1, 2002, the payer's internal dispute process must be finalized within 60 days of the provider's request. A dispute cannot simply sit.
- Filing floors. Payers cannot require initial filing sooner than 6 months from the date of service for outpatient claims, and a secondary claim gets 90 days from the primary payer's determination.
- The underpayment window. Providers get 12 months from the payment date to claim an underpayment — non-waivable by contract. That rule deserves its own note: Florida's 12-month underpayment rule.
- The recoupment mirror. Payer clawbacks against physicians are capped at 12 months after payment (fraud excepted), and the practice has 35 days to contest a demand in writing.
Who it covers — and who it doesn't
These are state insurance statutes, so they bind fully-insured Florida-regulated plans. Self-funded employer plans are preempted by federal ERISA law, and Medicare Advantage runs on federal rules — the card alone won't tell you which is which, so funding status is a per-claim check (group number or benefits documents), not an assumption. Workers' comp runs on an entirely separate state regime with its own, much shorter clock — see the Florida workers' comp note.
How to use it
- Timestamp everything. The clocks run from receipt, so proof of submission is the whole game. Archive claim-level clearinghouse acceptance reports — they start the prompt-pay clocks and double as timely-filing evidence later (the CO-29 note covers the proof hierarchy).
- Age open claims against the 20/90/120 marks, per payer. A claim sitting unadjudicated past 120 days deserves a statute-citing letter, not another status call.
- Compute the interest. Where the payer is Florida-regulated, state the 12% figure and the date it started running.
- Route underpayments to the statutory window. Short payments discovered late are statutory claims with a 12-month life, not late contractual appeals.
None of this is specialty-specific. The same statute governs a dermatology biopsy, a screening colonoscopy, a cataract surgery, and a spinal injection — if the plan is Florida-regulated, the clocks apply. What differs by specialty is only volume and dollar size, which decide how much an unworked clock costs you.