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Florida Medicaid Alerts

Florida Medicaid Health Care Alert – October 11, 2017

Provider Type(s): All

Payment Error Rate Measurement Information for Medicaid and Children’s Health Insurance Program Providers Regarding Medical Record Requests

The Payment Error Rate Measurement (PERM) program measures improper payments in the Medicaid and Children’s Health Insurance Program (CHIP) and produces error rates for each program.  The Centers for Medicare and Medicaid Services (CMS) developed this program to comply with the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) and related guidance issued by the Office of Management and Budget.

The PERM error rates are based on reviews of fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the federal fiscal year (FFY) under review. It is important to note the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.  FFY 2008 was the first year in which CMS reported error rates for each component of the PERM program.

Beginning in late calendar year 2017, CNI Advantage, LLC, the federal review contactor (RC) under PERM, will be reaching out to Medicaid and CHIP providers whose claims have been selected for review in a sample measurement conducted under the 2017 PERM project.  If a claim from your office has been selected for review, you will be receiving a call from a CNI Advantage, LLC representative to verify the appropriate contact and address to mail and/or fax the medical records request pertaining to the sampled claim.  Once this information is verified, the medical records request will be sent to that contact person requesting all medical records pertaining to the sampled claim.

Records must be submitted to CNI Advantage, LLC within seventy-five (75) calendar days from the date you are contacted.  Follow-up contact regarding these medical record requests may be made by Florida Medicaid staff if any request is nearing the 75 day time limit.

If the requested supporting medical documentation is not submitted, the claim will be coded as an error and any monies paid will be recouped.  Since dollars estimated as being paid in error are projected to all claims, the actual impact of each claim error will be magnified several times, resulting in an overall and exponentially negative impact on the Florida Medicaid program.  If the error rate is excessive, the Agency may be required to add controls or other limitations to address problem areas that are identified. It must be emphasized that even small dollar claim amounts identified as payment errors can have a significant impact on how a particular service area is perceived.  As such, it is important that providers submit requested medical records in a timely manner.

Please note that providers are required by Section 1902(a)(27) of the Social Security Act to retain records necessary to disclose the extent of services provided to individuals receiving assistance and furnish CMS, and its contractors, with information regarding any payments claimed by the provider for rendering services.  Furnishing information includes submitting medical records for review.

The collection and review of protected health information contained in individual-level medical records for payment review purposes is permissible by the Health Information Portability and Accountability Act of 1996 (HIPAA) and stated in 45 Code of Federal Regulations, parts 160 and 164.

If you would like to see a sample of the medical records request letter or you need more information related to PERM and your role in this process, please visit the CMS PERM website at

Please look for additional details as they become available from the PERM RC in upcoming Provider Alerts and on the Agency’s website (

For PERM related inquiries, you can contact us at

Florida Medicaid Health Care Alert – October 4, 2017

Provider Type(s): 01, 25, 26, 29, 30, 65, 66, 68,70, 77, 78, 89, 90

Florida Medicaid End Stage Renal Disease and Peritoneal Dialysis Webinar

The Agency for Health Care Administration is providing a webinar for physicians, dialysis providers, and managed care organizations to ensure that all Medicaid recipients with End Stage Renal Disease are educated and assessed by their physician and dialysis provider to determine their suitability for peritoneal dialysis (PD) as a modality choice, per Section 3, Chapter 2017-70 Laws of Florida, located on the Florida Department of State, State Library and Archives of Florida website.

At the conclusion of the webinar, the Agency will seek feedback from the dialysis community on methods suitable voluntary reporting to the Agency, on recipient’s suitability for PD.

The webinar is scheduled on Tuesday, November 7, 2017 from 10:00 to 11:00 a.m., EST. Please utilize the below link to register prior to the webinar.

View System Requirements

FOLLOW-UP to PT 17-18: Managed Care Plan Provisional Enrollment Notification-October 2, 2017

Policy Transmittal 17-18, Provision of Services During and After the Disaster Grace Period for Hurricane Irma, dated September 21, 2017, states that managed care plans must ensure that providers, not known to Florida Medicaid and who rendered services during the recent disaster, complete the Agency’s provisional (temporary) enrollment process in order to obtain a provider identification number.

For providers within the State of Florida, along with out-of-state providers, who are not enrolled with Florida Medicaid and who provided services to Florida Medicaid recipients, Florida Medicaid created a provisional provider enrollment process which includes waiving the requirements for providers to submit documentation showing the nature of the treatment, along with other normally-required information, when applying for provisional enrollment. The goal of the process created by Florida Medicaid and its fiscal agent (DXC Technology) is to minimize the administrative effort required by providers to get paid for services they rendered to those Florida Medicaid recipients impacted by Hurricane Irma.

For fee-for-service provisional enrollment, Florida Medicaid requires the following:

Managed care plans performing provisional enrollment can accept the same or similar items used by your managed care plan when enrolling out-of-network providers. Managed care plans should then email a completed Florida Medicaid Statewide Medicaid Managed Care Provisional Out-of-network Provider Enrollment form (attached) to DXC Technology, at DXC will add the provider to the Florida Medicaid Management Information System (FLMMIS) and the Provider Master List (PML), so that encounters will successfully process in the FLMMIS. Managed care plans do not need to include the items detailed above with the provisional enrollment form submission.

This temporary enrollment process is designed to facilitate the claims payment process and encounter data submission for those providers caring for the needs of our Medicaid recipients who were impacted by the recent disaster.  Please ensure the Hurricane Irma information that has been posted on your website relating to provider enrollment is updated to reflect the above information.

Thank you for your help in ensuring the continuity of care and safety for our Florida Medicaid recipients during and after Hurricane Irma.

Florida Medicaid Health Care Alert – September 22, 2017

Provider Type(s): All

Instructions for Enrollment and Payment for Services Rendered During the Hurricane Irma Disaster

The purpose of this alert is to provide detail on how to implement the 9/8/17 provider alert, Guidance to All Providers Regarding Provision of Services During Hurricane Irma: This Guidance Applies for Both Fee-For-Service and Managed Care Providers.

The Agency for Health Care Administration (Agency) will ensure reimbursement for services provided in good faith to eligible Florida Medicaid recipients during the Hurricane Irma disaster grace period. The Agency’s Hurricane Irma disaster grace period is from 9/7/17 through 9/21/17.

Section I of this alert provides updated policy guidance and applies to services rendered through both the fee-for-service (FFS) delivery system and the Statewide Medicaid Managed Care (SMMC) program, unless otherwise stated.

Section II of this alert provides reimbursement/payment guidance and applies to services rendered in the FFS delivery system, unless otherwise specified.

Section I: Policy Guidance

Services Provided During the Disaster Grace Period (9/7/17 through 9/21/17)

Prior Authorization Requirements

  • Florida Medicaid waived all prior authorization requirements for Medicaid services with dates of service during the disaster grace period.

Limits on Services

  • Florida Medicaid waived limits on services (specifically related to frequency, duration, and scope) that were exceeded in order to maintain the health and safety of recipients for dates of service during the disaster grace period.
    • Florida Medicaid lifted all limits on early prescription refills during the disaster grace period for maintenance medications, with the exception of controlled substances. The edits prohibiting early prescription refills will remain lifted until further notice by the Agency.

Provisional Enrollment

  • To be reimbursed for services rendered to eligible Florida Medicaid recipients on the dates of service in the disaster grace period, providers not already enrolled in Florida Medicaid (out-of-state or in-state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at

Services Provided Outside of the Disaster Grace Period

  • Florida Medicaid (fee-for-service and Medicaid health plans) may reimburse for services provided before the disaster grace period, on a case-by-case basis, if the service was necessary to maintain health and safety. Florida Medicaid will only approve instances in which early evacuations in parts of the state resulted in the recipient receiving care in a different region or out-of-state or if it was necessary for the recipient to refill a prescription early.
  • For dates of service beginning 9/22/17, Florida Medicaid (fee-for-service and Medicaid health plans) will return to normal business operations as it relates to the coverage and reimbursement of Medicaid services, except as described below:
    • Florida Medicaid will continue to reimburse for services furnished after the disaster grace period without prior authorization and without regard to service limitations or whether such services are provided by a current Medicaid enrolled provider in those instances where the provider and/or recipient could not comply with policy requirements because of ongoing storm-related impacts. Providers must have rendered services in good faith to maintain the recipient’s health and safety. Examples of such instances include:
      • The provider still does not have access to the Internet or phone services as a result of continued power outages, therefore could not request prior authorization timely;
      • The recipient continues to be displaced and must receive services in a different region of the state or out-of-state; or
      • The recipient’s assigned primary care physician or specialist’s office remains closed due to the storm and urgent care is rendered at another provider’s location without prior authorization.
    • Florida Medicaid will expedite authorization for new authorization requests submitted from September 22, 2017 through September 30, 2017, for durable medical equipment and supplies and home health services.
      • Florida Medicaid will complete the reviews for expedited authorizations within forty-eight (48) hours after receipt of the request for service. Florida Medicaid may extend the timeframe for expedited authorization decisions by up to two (2) business days if the recipient or the provider requests an extension or if additional information is needed to process the request, and the extension is in the recipient’s interest.

Section II: Payment Guidance

General Requirements

The Agency and its Medicaid health plans will implement claims payment exceptions processes for any medically necessary services furnished during the disaster grace period that normally would have required prior authorization, that were rendered by a non-participating provider, or that exceeded normal policy limits for the service.

Providers that furnished services to Medicaid health plan enrollees should work directly with each plan on reimbursement protocols. The Agency is requiring that Medicaid health plans create a web page dedicated to providing detailed instructions to providers for how to seek reimbursement through each Medicaid health plan’s claims payment exceptions process. A direct link to each plan’s claims payment exceptions website will be located on the Agency’s website by September 26, 2017.

Providers that wish to receive payment for services rendered during and outside of the disaster grace period are required to be enrolled with Florida Medicaid or provisionally enrolled with Florida Medicaid prior to submitting claims. For services provided to recipients receiving services through the FFS delivery system, provisional providers should submit claims in accordance with the instructions located at:

Providers Currently Enrolled with Florida Medicaid

Providers that furnished services to recipients receiving services through the FFS delivery system must comply with the requirements below:

  • For services provided during the disaster grace period, providers may submit electronic claims in accordance with normal HIPAA compliant transaction requirements if the service requires a prior authorization number, but prior authorization was not obtained.
  • For services provided during the disaster grace period, providers may submit paper claims as described in the Agency’s exceptional claims process if service limitations exceeded those stated in the coverage policy or the respective fee schedule.
  • For services provided outside of the disaster grace period because of storm-related impacts (See Section I of the alert), providers may submit paper claims as described in the Agency’s exceptional claims process.

Reimbursement Rates (for services provided during the disaster grace period)

  • Florida Medicaid will reimburse for services provided through the FFS delivery system in accordance with the rates established on the Medicaid fee schedules and the provider reimbursement rates/reimbursement methodologies published on the Agency’s web page. This applies to current enrolled providers and providers that complete the provisional enrollment process.
    • The Agency’s web page includes links to the Diagnosis-Related Groups and Enhanced Ambulatory Patient Grouping System rate calculator, which provisionally-enrolled providers can utilize.
    • Nursing facilities will receive reimbursement for applicable scenarios as detailed in Section 8.0 of the Florida Medicaid Nursing Facility Coverage Policy. For instances not detailed in the coverage policy, the nursing facility will receive the Florida Medicaid nursing facility statewide weighted average rate, which is $227.68 per day.
  • The Medicaid health plans will reimburse participating network providers for services provided at the rates mutually agreed upon by the provider and the plan in their contract/agreement. The Medicaid health plans will reimburse non-participating providers (i.e., providers not already contracted with the Medicaid health plan), for services provided in accordance with the rates established on the Medicaid fee schedules and the provider reimbursement rates/reimbursement methodologies published on the Agency’s web page, unless otherwise mutually agreed upon by the provider and the Medicaid health plan.

Additional Information

Maintenance of Supporting Documentation

  • Providers rendering services must maintain as much documentation as possible to help properly and timely adjudicate claims. Nothing precludes the Agency or its Medicaid health plans from conducting retrospective reviews to detect any fraud or abuse.

Agency’s Hurricane Irma Website

  • Additional information for providers is located on the Agency’s website, Click on the Hurricane banner at the top of the page for more information.

Medicaid Contact Center

Additional questions from providers may be directed to the Florida Medicaid Contact Center at 1-877-254-1055.

Florida Medicaid Health Care Alert – September 14, 2017

Provider Type(s): All

Summer 2017 Florida Medicaid Provider Bulletin Now available

The Summer 2017 Florida Medicaid Provider Bulletin is now available on the Florida Medicaid website. The bulletin contains articles related to:

  • AHCA Releasing the Invitation to Negotiate for SMMC Re-Procurement
  • Florida Medicaid Adopted Policies 2016-17
  • Florida Medicaid Policies in Process 2017-18
  • Florida Medicaid Promulgated Fee Schedules
  • New Medicaid Report Providing Critical Data for Quality Improvement
  • EAPG Pricing Implementation




Florida Medicaid Health Care Alert – September 8, 2017

Provider Type(s): All

Guidance to All Providers Regarding Provision of Services During Hurricane Irma: This Guidance Applies for Both Fee-For-Service and Managed Care Providers

It is imperative Florida Medicaid recipients maintain access to services during the disaster period. To this end, the Agency will ensure reimbursement for services that are provided in good faith to eligible recipients:

Please keep providing services:

  • The Agency will waive all prior authorization requirements for Medicaid services during the disaster period.
  • Early prescription refill edits have been lifted for all maintenance medications (this does not apply to controlled substances).
  • If a recipient requires services beyond limits stated in policy in order to maintain safety and health, providers can furnish the service.
  • For providers furnishing services out of state or for providers not currently enrolled in Florida Medicaid, we encourage you to provide needed services to any Florida Medicaid recipient who has been displaced.

Medicaid transportation services:

  • Medicaid transportation providers are continuing to provide transportation to critical medical services, such as chemotherapy and dialysis and inter-facility transfers, when the facilities providing those services remain available and when the safety of the recipient and the driver can be assured. 
  • As evacuations occur and Hurricane Irma moves closer to Florida, Medicaid transportation providers are making county by county assessments regarding the availability of providers and their ability to ensure safety.

Out-of-state or non-Medicaid providers:

  • For reimbursement purposes, the Agency will expedite enrollment for out-of-state or non -Medicaid providers on a provisional (temporary) basis after services are rendered. The process for provisional provider enrollment is located at
  • All out-of-state or non-enrolled providers wishing to provide services should provide services. Pharmacies needing to immediately dispense prescription refills to displaced Florida Medicaid recipients should dispense the prescriptions and follow the provisional enrollment process.
  • Providers that are not enrolled in Florida Medicaid that furnish services during this emergency period should maintain as much documentation as possible to help the Agency properly and timely adjudicate claims after the storm. This includes:
    • Recipient information
    • Services rendered with dates and location
    • Information on the nature of the emergency necessitating the provision of services (if applicable)

Additional information for providers is located on the Agency website,  Click the Hurricane banner at the top of the page for more information

Florida Medicaid Health Care Alert – September 1, 2017

Provider Type(s): All

Notification of Changes to the National Provider Identifier (NPI) Registration Process

The Agency for Health Care Administration (Agency) is announcing that an update to the NPI registration process was implemented on August 25, 2017.

Changes include:

  • A new validation process to prevent adding the same NPI information to multiple provider records. Should NPI information submitted as part of an application or an update to an existing provider record already exist on another provider record, the new NPI information will be rejected. The provider will receive an error message directing them to submit a modified NPI information request.
  • An online, searchable Taxonomy Guide provided to view a list of taxonomies appropriate for each provider type and specialty.
  • An interactive menu for selection of taxonomies on the Web-based Provider Enrollment Wizard. The menu will present a dropdown list of the taxonomies that are appropriate for the provider type and specialty entered on the application. This new feature will be available on both the Provider Type and Specialty panel and the NPI panel.
  • A new “Date Used for Claims” field will be associated with the NPI on a provider’s record. This field indicates whether the date of service on a claim or the date the claim is submitted will be used by Medicaid in matching the claim NPI to a Medicaid provider record.
    •     “Date of Service” – The claim’s NPI must be on the provider’s record for the date of service, regardless of date of submission.
    •     “Date of Submission” – The claim’s NPI must be on the provider’s record for the date of submission, regardless of date of service.

Providers can view the “Date Used for Claims” field on their secure Web Portal page.

The Agency has posted three NPI-related documents on the Enrollment Forms page of the public Web Portal as part of this process change.

NPI Registration Form: Requires a valid taxonomy code and ZIP code when updating an NPI crosswalk for Florida Medicaid.

NPI Registration Guide:  Contains useful information to assist providers when filling out the NPI Registration Form.

Florida Medicaid Taxonomy Guide: Provides a searchable list of the taxonomies by provider type and specialty. This is a valuable resource when completing an NPI Registration Form or preparing to submit a new Medicaid provider enrollment application.

NOTE: The Agency will continue to accept the old NPI Registration Form through October 31, 2017. After October 31, 2017, only the revised NPI Registration Form (August 2017) will be accepted.

Providers may contact the Provider Enrollment Call Center at 1-800-289-7799, option 4, or their local Field Services Representative for any assistance with the enrollment process.




Florida Medicaid Health Care Alert – August 24, 2017

Provider Type(s): All

Background Screening Required for All Florida Medicaid Providers

All providers seeking to enroll or renew their enrollment in Florida Medicaid must undergo a background screening, including submission of fingerprints, per § 409.907, F.S. Background screenings must be renewed every five (5) years. All screenings must be initiated in the Care Provider Background Screening Clearinghouse (Clearinghouse). The requirement to be screened applies equally to providers receiving direct reimbursement from Florida Medicaid and/or receiving reimbursement from a Medicaid health plan.

Providers should review their records in the Clearinghouse to verify that a current eligible status is present prior to submitting their Medicaid application. If not, providers must either undergo a new background screening to be added to the Clearinghouse or have their existing Clearinghouse screening resubmitted in order to obtain updated results. NOTE: New Clearinghouse screening results take a few days to become available to Medicaid.

Applications for providers that do not have a current background screening on file in the Clearinghouse will be returned to providers.

Once providers receive written acknowledgement of their eligible screening from the Clearinghouse, they can upload a copy of the acknowledgement letter to Medicaid in order to begin or restart the application process.

Providers should:

  • Visit the public Web Portal Background Screening page to access additional information on background screenings and the Clearinghouse.
  • Call the Provider Services Call Center at 1-800-289-7799, option 4, for any assistance with the renewal process.





Florida Medicaid Health Care Alert – August 22, 2017

Provider Type(s): 65

Moratorium Extension-Home Health Agency Provider Enrollment

Provider Type(s): 65

The Centers for Medicare & Medicaid Services (CMS) have extended the temporary moratorium on enrollment of home health agencies in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) for an additional six months effective July 29, 2017.

The goal of the temporary moratorium is to fight fraud and safeguard taxpayer dollars, while ensuring patient access to care. Authority to impose such moratorium was included in the Affordable Care Act.

The temporary moratorium applies to all newly-enrolling home health agencies in all counties in Florida. CMS announced the temporary moratoria in a notice issued July 28, 2017 in the Federal Register.

In compliance with this moratorium, the Agency for Health Care Administration will deny any new or pending applications for licensed home health providers effective July 29, 2017.

Under the moratorium, existing home health agency providers and suppliers can continue to deliver and bill for services, but no new provider and supplier applications will be approved for a period of six months.

This moratorium does not apply to home health agencies seeking to enroll as the result of a documented change of ownership as defined in 408.803, F.S.

Florida Medicaid Health Care Alert – August 15, 2017

Provider Type(s): 01, 25, 26, 29, 30, 32, 34, 66, 69,70, 77,78

(Clarification) Long-Acting Reversible Contraceptive Inpatient Reimbursement (Fee-for-Service Delivery System)

In the fee-for-service delivery system, Florida Medicaid reimburses for immediate postpartum placement of long-acting reversible contraceptives (LARCs) separate from the inpatient hospital labor and delivery Diagnosis Related Group (DRG) payments. Medicaid health plans have the flexibility to negotiate mutually agreed upon reimbursement arrangements with their network providers. For more information on reimbursement of LARC devices immediate postpartum for health plan enrollees, please contact each health plan directly.


Providers rendering services through the fee-for-service delivery system can seek reimbursement for LARCs by utilizing the codes listed below. This reimbursement policy change became effective October 1, 2016 and was communicated to Medicaid providers via the updated Inpatient Hospital Services coverage policy, effective July 11, 2016. This system change was implemented to support the Agency’s goal of improving birth outcomes. Research shows that LARCs are effective in reducing unintended pregnancies, premature and low birth weight births, and prenatal drug exposure.

Devise Insertion and Removal Procedure Codes:

11981 Insertion, non-biodegradable drug delivery implants
11982 Removal, non-biodegradable d rug delivery implants
11983 Removal with reinsertion, non-biodegradable drug delivery implant
58300 Insertion of IUD
58301 Removal of IUD

LARC Device:


* systems are currently being updated to include this temporary code

Note: National Drug Codes (NDC) should be included. The only limit on these products is 1 unit per claim, up to 3 claims per year.

The Agency’s effort to facilitate access to LARCs immediately postpartum is in collaboration with community partners, Medicaid health plans and other state partners, which include the Florida Perinatal Quality Collaborative (FPQC). The FPQC has established the “Access LARC” Initiative to provide training and resources in efforts to help Florida hospitals set up delivery and billing systems needed for immediate postpartum placement of LARC implementation. If a hospital is interested in participating in this initiative, then visit the Access LARC website for more information.

Send an email to the Florida Perinatal Quality Collaborative at to obtain a list of recruited hospital contacts participating in this initiative.

If you need assistance, please contact a Medicaid representative at 1-877-254-1055.


Florida Medicaid Health Care Alert – January 2016

Provider Type(s): All

New Children’s Medical Services Plan Clinical Eligibility Process Begins January 11, 2016

Effective Monday, January 11, 2016, a new Florida Department of Health rule will govern how children can be determined clinically eligible for the Children’s Medical Services Medicaid Managed Medical Assistance plan (CMS plan). Under Rule 64C-2.002 of the Florida Administrative Code, treating physicians may attest to a current diagnosis and functional limitation qualifying children with chronic and serious conditions as a referral for enrollment into the CMS plan.

If you are the treating physician of a child and you would like to attest to the eligibility of your patient for the CMS plan, please review the CMS Clinical Eligibility Attestation for Physicians and a list of qualifying chronic and serious conditions. Completed and signed attestations can be submitted by the physician to the Department of Health via secure email at or via fax to (850) 488-3813. Please be sure to submit all five pages of the attestation.

NOTE: Friday, January 8, 2016, is the last day the Agency for Health Care Administration will process requests for enrollment in the Children’s Medical Services plan through the Interim Process to Qualify for Enrollment in the Children’s Medical Services Plan.

If physicians have questions about the CMS Clinical Eligibility Attestation, please contact a CMS plan nurse at (850) 245-4444, extension 3291.

General information about the CMS plan and available services is located at

Florida Medicaid Health Care Alert – December 2015

Provider Type(s): 70

Streamlined Credentialing Webinar Registration Now Available

The Agency for Health Care Administration has created a Streamlined Credentialing process, or Limited Enrollment, for providers seeking to participate in Medicaid managed care. The Limited Enrollment provider application captures demographic information for the applicant and the Agency will perform basic credentialing activities such as verifying licensure, exclusion databases, and background screening results in compliance with the Affordable Care Act provider screening requirements.

As of December 4, 2015, providers who do not hold a Medicaid ID and need to complete basic credentialing can submit a Limited Enrollment provider enrollment application through the Florida Medicaid Public Web Portal.

NOTE: Any provider who will submit FFS claims directly to Medicaid must be fully enrolled.

The Agency and their fiscal agent, Hewlett Packard Enterprise, invite the health plan community to participate in a series of upcoming webinars on the Streamlined Credentialing application. Webinars will take place on January 20, 2016 from 1:00-2:00 PM EST and January 21, 2016 from 2:00-3:00 PM EST.

To register, visit For questions or additional information, please contact

Florida Medicaid Health Care Alert – November 2015

Provider Type(s): All

Interim Process to Qualify Children for Enrollment In the Children’s Medical Services Plan

Children with chronic and serious conditions may choose to enroll in the Children’s Medical Services specialty plan (CMS plan). To qualify for enrollment in the CMS plan, the child’s physician must submit a letter to the Agency for Health Care Administration attesting that the child’s current diagnosis is one of the qualifying chronic and serious conditions listed below.

This is a time-limited process that will end once the Department of Health promulgates a rule specifying how children can qualify for the CMS plan.

The instructions for the physician’s attestation are on the Agency for Health Care Administration’s Medicaid Web pages for Recipient Support and Provider Services.

The Statewide Medicaid Managed Care contract for the CMS specialty plan defines chronic and serious conditions as one or a combination of the following conditions: acute or chronic lymphoid leukemia; acute or chronic myeloid leukemia; congenital or acquired quadriplegia; congenital diplegia or hemiplegia; spina bifida; malignant neoplasm of the esophagus, stomach, small intestine, pancreas, ovary, kidney, brain, unspecified part of the nervous system, or lung; human immunodeficiency virus (HIV) disease; persistent vegetative state; cystic fibrosis; heart failure; chronic kidney disease, stage IV and V; end stage renal disease; schizophrenia; major depressive disorder, recurrent, severe, with or without psychotic features; bipolar I disorder, severe; anorexia nervosa; bulimia nervosa; pyromania; intermittent explosive disorder; oppositional defiant disorder; failure to thrive – child; epilepsy, unspecified, without mention of intractable epilepsy; dysphagia; receptive-expressive language disorder; secundum atrial septal defect; perinatal chronic respiratory distress; or chronic respiratory failure.

Florida Medicaid Health Care Alert – September 2015

Provider Type(s): 01

Inpatient Stay Reprocessing

The Agency for Health Care Administration completed a review of Medicaid inpatient hospital claims, with dates of service from January 1, 2009 through June 6, 2014.

The Agency implemented a system enhancement in Florida Medicaid Management Information System, to correct the reimbursement of affected claims. As a result of the implementation, inpatient claims that were incorrectly reimbursed are being reprocessed for appropriate reimbursement. Providers affected by reprocessing will see claims adjusted in their Remittance Advice.

If you have any questions please contact Provider Services at (800) 289-7799 (option 7).

Florida Medicaid Health Care Alert – September 2015

Provider Type(s): 25, 26, 27, 28, 29, 30, 31, 34, 35, 36, 60, 61, 62, 63, 66, 68, 69, 70, and 77

Provider Fee Schedule Update

Effective September 3, 2015 the Florida Agency for Health Care Administration (AHCA) will be utilizing the rates published on the January 1, 2015 practitioner fee schedules. The January 1, 2015 fee schedules will be used until further notice. Claims reimbursed at the rates published on the August 1, 2015 fee schedules will be reprocessed in accordance with the rates specified on the January 1, 2015 fee schedules. Although not required, providers have the option of voiding and resubmitting their claim(s) ahead of the reprocessing.

The affected fee schedules are as follows:

  • Advance Registered Nurse Practitioner
  • Chiropractic
  • Dental General
  • Hearing
  • Independent Lab
  • Licensed Midwife
  • Optometric
  • Oral Maxillofacial Surgery
  • Outpatient Hospital Laboratory

  • Physician Assistant
  • Physician Evaluation and Management
  • Physician Laboratory
  • Physician Medical
  • Physician Radiology
  • Physician Surgical
  • Podiatry
  • Registered Nurse First Assistant
  • Visual

The January 1, 2015 fee schedules can be found at

For further questions regarding the fee schedule updates please contact Medicaid Program Finance at

Florida Medicaid Health Care Alert – July 2015

Provider Type(s): 70

Effective Dates for Providers Seeking to Register with Medicaid

The Agency for Health Care Administration has directed the Medicaid fiscal agent, HP Enterprises, LLC, to set the effective date for newly-registered providers to the date the registration is received, in keeping with 409.907, F.S. The change is effective for registrations received after July 1, 2015.

The previous exception to effective dates which allowed the effective date for newly-registered providers to be one year prior to receipt of the registration is sunset. This exception was enforced throughout the implementation of Statewide Medicaid Managed Care to support the rapid development of health plan networks which required the assignment of Medicaid IDs to many providers.

This action is taken with consideration for health plans who may contract with a provider who supplies services to Medicaid eligible recipients prior to registering with Medicaid. On a case-by-case basis, health plans can submit a written request for consideration of an effective date equal to the first date of service. The request should be included with the registration form when submitted to the Medicaid fiscal agent. The request will be reviewed by Agency staff who will instruct the fiscal agent when an exception to the date of receipt effective date rule will be granted.

If plans have any questions regarding this message, please contact the Provider Enrollment Contact Center at 1-877-289-7799, Option 4 for assistance.

Florida Medicaid Health Care Alert – July 2015

Provider Type(s): 25, 26, 27, 28, 29, 30, 31, 34, 35, 36, 60, 61, 62, 63, 66, 68, 69, 70, and 77

Provider Fee Schedule Update

Florida’s 2015 Special Legislative Session A concluded on June 19, 2015, resulting in a delay of budget finalization. Fee schedules for state fiscal year 2015-16 could not have been updated prior to final action by the Legislature and Governor on the state budget for the fiscal year. As a result, the following fee schedules will be updated with an effective date of August 1, 2015:

  • ARNP
Physician Immunization
  • Birth Center
  • Physician Laboratory
  • Chiropractic
  • Physician Medical
  • Dental General
  • Physician Pediatric Spec
  • Dental Injectables
  • Physician Primary Care Rates
  • Hearing
  • Physician Radiology
  • Independent Lab
  • Physician Surgical
  • Licensed Midwife
  • Physician Durable Medical Equipment
  • Optometry
  • Podiatry
  • Oral MaxFac
  • RNFA
  • Physician Anesthesia
  • RPICC Neo
  • Physician Assistant
  • RPICC Ob
  • Physician E&M
  • Visual

Florida Medicaid Health Care Alert – May 2015

Provider Type(s): All: National Provider Identifier (NPI) to Medicaid ID Search Engine

The Agency for Health Care Administration in conjunction with the Medicaid fiscal agent, HP Enterprises, LLC, has developed an online National Provider Identifier (NPI) to Medicaid ID Search Engine which allows users to search by an NPI and view the Medicaid IDs with which it is associated.

With this information, users can determine, before a claim is submitted and possibly denied, if the NPI they will be listing at either the rendering or billing level will result in a single unique match to a provider ID in the FLMMIS. An NPI as submitted in a claim must match to a single provider ID in order for the claim to pass the edits which verify that the provider is an active Medicaid provider.

If the search reports multiple provider IDs, users may add groupings of NPI, Taxonomy, and/or ZIP+4 to the search in an attempt to locate a single match. Regarding use of these elements in claims:

  • For billing submissions, a combination of an NPI, Taxonomy, and Zip code can be used on claims to find a unique match to a provider file.
  • For rendering submissions, only the NPI and Taxonomy can be used. The NPI search tool was created to allow for these differences.

Note: Only active NPIs that have an end date within the last year or later are displayed in the search results.

Accessing the NPI to Medicaid ID Search Engine

The NPI to Medicaid ID Search Engine can be found on the Medicaid Public Web Portal at The application can be accessed from either the Support section of the Provider Services drop-down menu or from the Managed Care menu accessed by clicking the Managed Care link.

For further assistance with inquiries related to this announcement, email

Florida Medicaid Health Care Alert – May 2015

Provider Type(s): All: Children’s Medical Services Clinical Screening

The Florida Department of Health is implementing a new, national screening tool for children with special health care needs that is used by several other states. The timeline for screening children in Medicaid (Title 19) CMSN will begin in May, and is as follows below. Children in Title 21 (CHIP) will be not be re-screened until August or September 2015.

For Title 19 (Medicaid) Re-Screening:

May: Families with children in CMSN receive a letter informing them of the screening process.

May through July: Screenings with the new tool take place via telephone call to families. Children determined not to meet CMSN clinical criteria receive a letter explaining the next steps and then receive materials from Medicaid with information on how to choose a new Managed Medical Assistance plan. All children will have a minimum of 30 days to choose a plan.

July through September: Children who are not clinically eligible for CMSN begin being served by new MMA plans. The start date of enrollment is based on when the screening was completed.

Every Managed Medical Assistance plan provides all medically necessary services to children, so families can choose plans based on factors such as which providers are in the network and what extra benefits the plan provides. If families have more than one child on Medicaid and wish to have their children served by the same health plan, there are options available. Families should call Medicaid Choice Counseling for more information.

The following protections apply for any Medicaid recipient who changes health plans:

  • Health care providers should not cancel appointments with current CMSN patients. Health plans must honor any ongoing treatment that was authorized or scheduled prior to the recipient’s enrollment into the new health plan for up to 60 days after the child enrolls in the plan.
  • Providers will be paid. Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Plans must pay providers for previously authorized services for up to 60 days, and must pay non-network providers at the rate previously received for up to 30 days.
  • Prescriptions will be honored. Plans must allow recipients to continue to receive their prescriptions through their current provider, for up to 60 days, until their prescriptions can be transferred to a provider in the plan’s network.

For more information, please visit the Florida Department of Health website.

Florida Medicaid Health Care Alert: April 2015

Provider Type(s): All – Medicaid Eligibility for Newborn Babies

A new Medicaid information document entitled “Medicaid Eligibility for Newborn Babies” is now available on the Florida Medicaid Public Web Portal.

The publication covers basic information on newborn eligibility and activation:

  • Unborn Activation Process
  • Enrollment in a Managed Medical Assistance Plan
  • Enrollment in an MMA Specialty Plan
  • Voluntary Change of MMA Plan for Baby
  • Not Enrolled in MMA Plan
  • Unborn Does Not Have a Medicaid Number
  • Newborn FAQs

The document may be found on the Statewide Medicaid Managed Care web page and on the Medicaid Policy and Quality web page.

Florida Medicaid Health Care Alert: April 2015

Provider Type(s): 01 and 70 – Updated Outpatient Laboratory Fee Schedule

The Agency for Health Care Administration has published the new Outpatient Hospital Laboratory fee schedule; with an effective date of January 2015. The updated fee schedule can be found at Select Provider Services and then under Support select Fee Schedules.

The 2015 Outpatient Laboratory fee schedule will no longer include follow-up days (FUD) or units of service (UOS). Florida Medicaid utilizes the National Correct Coding Initiative Medically Unlikely Edits (MUE) for units of service.

Providers receiving reimbursement through a Medicaid managed care plan should refer to their contract with each plan to determine whether this change will impact their reimbursement from the plan.

Florida Medicaid Health Care Alert: April 2015

Agency Disclosure of Provider/Recipient Information

In accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations, Agency representatives are not allowed to disclose provider claim or other information, including recipient protected health information (PHI) to individuals who are not authorized representatives of a Medicaid provider. Authorized representatives include the provider’s employees and any registered billing agents with a Medicaid provider ID (provider type 99).

To receive provider information, the billing agent must also be associated with the provider’s file through the submission of an Electronic Data Interchange (EDI) agreement. Providers may not use an unrelated third-party who is not enrolled in Medicaid as a billing agent. Please contact Medicaid Provider Enrollment at 1 (800) 289-7799, option 4, for information on enrolling as a Medicaid billing agent, or linking to a provider file as a trading partner.

Agency representatives will not disclose any provider information to parties who do not meet the criteria described above.

Ebola Alert for Providers

October 9, 2014 – Florida’s Agency for Health Care Administration (AHCA) released a statement to providers and health plans in the state of Florida regarding Ebola and standard reporting procedures for communicable diseases in the state of Florida. As noted in the letter, “Much of this information has already been delivered to individual providers (physicians, laboratories, hospitals, etc.) by the Florida Department of Health.  It is our intent to keep our Agency partners informed and encourage the dissemination of this information as broadly as you deem appropriate.”

AHCA’s list of resources for providers includes those from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the Florida Department of Health:

Centers for Disease Control and Prevention:

Signs and Symptoms, Transmission, Prevention, Information for Health Care Workers, One Page Fact Sheet 

World Health Organization: 

Protective Measures for General PublicProtective Measures for Medical Staff

Florida Department of Health: 

Ebola Overview (Video), Ebola Guidance Flyer (English/Spanish)

The following sources, taken from the Florida Department of Health, provide information regarding health care provider reporting guidelines for communicable diseases.

Health Care Practitioner Reporting Guidelines • List of Reportable Diseases/Conditions in Florida • Practitioner Disease Report Form

Additionally, DOH Letter 7-1-14 from the Florida Department of Health informs providers of the most recent changes to regulations pertaining to the reporting of communicable diseases in Florida. AHCA has asked that health organizations disseminate this information to healthcare providers and others. AHCA will continue to issue updates as appropriate.

Medicaid Alert Regarding State Licensure for Health Care Clinics

State licensing laws requires that health care clinics, unless specifically exempt from the requirement, be licensed by the Agency pursuant to Chapter 400, Part X, Florida Statutes. The statute defines a clinic as “an entity at which health care services are provided to individuals and which tenders charges for reimbursement for such services, including a mobile clinic and a portable equipment provider.” It is the responsibility of the provider to know if their clinic is required to be licensed. It is improper to operate without a health care clinic license when one is required by law.

For more information about whether a license is required or whether you qualify for an exemption, visit the Agency’s website. Specific exemptions can be found by viewing the “Health Care Clinic Act” link on the website; specifically chapter 400.9905, 4(a)-(n), F.S.

The Agency is increasing efforts to ensure compliance with these provisions of law and encourages all Medicaid providers to review the law and take appropriate action to assure compliance. Failure to comply with the licensure requirements may result in sanctions as well as recovery of any overpayments. The Agency’s licensing Division of Health Quality Assurance (HQA), also monitors compliance and take action for unlicensed activity as appropriate.

Questions specific to the increased compliance efforts by HQA may be directed to the Health Care Clinic Unit via email at or by phone at (850) 412-4404.

For more information on the Medicaid program and Medicaid policies, contact your local Medicaid area office. Additionally, information about self audits and other compliance-related issues may be found on the Agency’s website, including the Medicaid Fraud and Abuse link and the Medicaid Training e-Library.

Message from the Florida DOH Regarding ICD-10

ICD-10 is fast approaching. The Centers for Medicare and Medicaid Services has an excellent website “Road to 10” available at no cost. Resources are available with downloadable ICD-10 files. Please visit for information.

Florida Medicaid Healthcare Alert: Important Change in Background Screening Process for Florida Medicaid

Background screening for new and renewing Medicaid providers will migrate to the Care Provider Background Screening Clearinghouse effective March 1, 2015.

The purpose of the Clearinghouse is to provide a single data source for background screening results of persons required to be screened by law for enrollment in Florida Medicaid. The Clearinghouse shall allow the results of criminal history checks to be shared among specified agencies when a person has applied to volunteer, be employed, be licensed, or enter into a contract that requires a state and national fingerprint-based criminal history check. (section 435.12, Florida Statutes).

A new Florida Medicaid ORI (EAHCA013Z) will take effect March 1, 2015. This ORI requires retained prints and a photograph. The new cost of the screening is $62.75 plus any handling fees charged by the Livescan vendor submitting the screening for the provider. The existing ORI (FL922013Z) will be invalid as of March 1, 2015 and WILL BE denied. If a submission is denied, providers must complete and pay for a new fingerprint using the new ORI (EAHCA013Z).

Medicaid providers are required to register applicants on the Clearinghouse website prior to screening; this will create a screening ID, or screening request ID, for use by Livescan vendors and providers. The new ORI will be passed to the Livescan vendor/service provider if an appointment is scheduled via the Clearinghouse website.

Clearinghouse website information is available on the AHCA public portal.

Florida Medicaid Health Care Alert: February 2015

Provider Type(s): 67 • Upcoming Changes to Agency for Persons with Disabilities Provider Background Screening Process

Florida Medicaid is transitioning background screening for new and renewing applicants to the ‘Care Provider Background Screening Clearinghouse’ or ‘Clearinghouse’ (CLH) effective March 2, 2015.

The purpose of the CLH is to provide a single data source for background screening results of care providers. It allows participating ‘Specified Agencies’ to share the results of criminal history checks when a person has applied to volunteer, be employed, be licensed, or enter into a contract that requires a state and national fingerprint-based criminal history check. This message will clarify how this transition affects APD providers.

When will APD providers start using the Clearinghouse?

APD providers will receive an email notification with instructions and training materials when it is time to register for the CLH results website. APD providers will register in phases by provider type (e.g., APD MW, APD Facility) as part of the DCF/APD on boarding phase scheduled for spring and summer 2015.

Please note:

  • Providers should ensure that DCF/APD has a current email address to receive notifications.
  • Providers will have time to register and view training videos posted online.
  • APD providers should continue to submit screenings under the existing system as normal until registration is complete and they receive another notification to use the Results Website.

Are providers required to screen all existing employees again through the CLH?

No. Providers will continue normal screening practices for new hires, existing employees at their 5-year rescreening date, and those with a lapse in employment that meets rescreening standards.

Providers with questions about this new process may visit DCF’s Background Screening webpage at The webpage offers more information on the Clearinghouse, along with step- by- step instructions on the process to begin submitting screenings through the Clearinghouse. Providers may also call the DCF Background Screening Help Desk at (888) 352-2842.

Florida Medicaid Health Care Alert, February 2015: From Florida Medicaid, A Division of the Agency for Health Care Administration

The February ICD-10 Newsletter is now available on the Florida Medicaid Public Web Portal.

You can download a copy of the February 2015 ICD-10 Newsletter under the Publications section of the ICD-10 pages.

In this issue:

  • ICD-10 Workshops and Webinars
  • Coding for ICD-10-CM: More of the Basics
  • Getting Ready for ICD-10 with CMS Resources
  • Community Behavioral Health – Autistic Disorder, Asperger’s Syndrome, etc.

The ICD-10 pages are updated often, so please visit regularly for the most current information.