BLANK HANDBOOK TEMPLATE 010610 - Florida

Florida Medicaid

PROVIDER GENERAL HANDBOOK

Agency for Health Care Administration

July 2012

UPDATE LOG FLORIDA MEDICAID PROVIDER GENERAL HANDBOOK

How to Use the Update Log

Introduction

The current Medicaid provider handbooks are posted on the Medicaid fiscal agent's Web site at mymedicaid-. Select Public Information for Providers, then Provider Support, and then Provider Handbooks. Changes to a handbook are issued as handbook updates. An update can be a change, addition, or correction to policy. An update may be issued as either replacement pages in an existing handbook or a completely revised handbook.

It is very important that the provider read the updated material and if he maintains a paper copy, file it in the handbook. It is the provider's responsibility to follow correct policy to obtain Medicaid reimbursement.

Explanation of the Update Log

Providers can use the update log to determine if they have received all the updates to the handbook.

Update describes the change that was made.

Effective Date is the date that the update is effective.

Instructions

When a handbook is updated, the provider will be notified by a notice. The notification instructs the provider to obtain the updated handbook from the Medicaid fiscal agent's Web site at mymedicaid-. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.

Providers who are unable to obtain an updated handbook from the Web site may request a paper copy from the Medicaid fiscal agent's Provider Support Contact Center at 800-289-7799.

UPDATE New Handbook Replacement Page Revised Handbook Revised Handbook Revised Handbook

EFFECTIVE DATE October 2003 January 2004 January 2007 July 2008 July 2012

Florida Medicaid Provider General Handbook

Table of Contents

Chapter/Topic

Page

Introduction

Handbook Use and Format ...................................................................................................... ii Characteristics of the Handbook .............................................................................................. iii Handbook Updates .................................................................................................................. iii

Chapter 1 - The Florida Medicaid Program

Organization and Administration ............................................................................................ 1-2 Types of Reimbursement ....................................................................................................... 1-3 Payment for Services ............................................................................................................. 1-4 Medicaid Copayment and Coinsurance ................................................................................. 1-9 Third Party Liability............................................................................................................... 1-12 Types of Third Party Resources .......................................................................................... 1-15 Medicaid Managed Care Programs ..................................................................................... 1-19 MediPass ............................................................................................................................. 1-21 MediPass Disease Management ........................................................................................ 1-24 Children's Medical Services (CMS) Network ....................................................................... 1-26 Health Maintenance Organizations (HMOs) ....................................................................... 1-27 Prepaid Mental Health Plan ................................................................................................ 1-32 Prepaid Dental Health Plan.................................................................................................. 1-32 Provider Service Networks (PSNs) ...................................................................................... 1-33 Home and Community-Based Services (HCBS) ................................................................. 1-40 Medicaid Special Services for Children ............................................................................... 1-42

Chapter 2 - The Florida Medicaid Provider

Provider Requirements .......................................................................................................... 2-2 Licensure and Certification .................................................................................................... 2-3 Non-Institutional Provider Enrollment ................................................................................... 2-6 Institutional Provider Enrollment ........................................................................................... 2-9 Effective Date of Enrollment ................................................................................................ 2-11 Provider Agreement ............................................................................................................. 2-12 Provider Identification Numbers, Suffix Codes and Specialty Codes .................................. 2-14 Group Providers ................................................................................................................... 2-19 Medicare Crossover ............................................................................................................. 2-20 Criminal History Check......................................................................................................... 2-23 Electronic Funds Transfer (EFT).......................................................................................... 2-27 Surety Bonds........................................................................................................................ 2-30 On-Site Reviews .................................................................................................................. 2-34 Non-Emergency Out-of-State Services................................................................................ 2-35 Out-of-State Enrollments...................................................................................................... 2-41 Denying Provider Enrollment ............................................................................................... 2-44 Provider Re-enrollment ........................................................................................................ 2-46 Provider Terminations .......................................................................................................... 2-46 Provider Reapplications after Termination........................................................................... 2-48 Reporting to the IRS............................................................................................................. 2-49 Change of Address Procedures ........................................................................................... 2-49 Change of Ownership .......................................................................................................... 2-50

Other Changes to Provider Records .................................................................................... 2-53 Provider Rights and Responsibilities ................................................................................... 2-57 Privacy of Recipient Information .......................................................................................... 2-58 Record Keeping Requirements ............................................................................................ 2-60 Counterfeit-Proof Prescription Blanks and Printed Prescriptions ....................................... 2-63 Billing Agents and Clearinghouses ...................................................................................... 2-65 Requesting Help................................................................................................................... 2-67

Chapter 3 - Medicaid Recipient Eligibility

Eligibility Determination.......................................................................................................... 3-2 Medicaid Identification Card................................................................................................... 3-3 Verifying Eligibility .................................................................................................................. 3-5 Managed Care Enrollment Verification ................................................................................ 3-10 Proof of Eligibility.................................................................................................................. 3-11 Limited Coverage Categories .............................................................................................. 3-21 5007 ..................................................................................................................................... 3-21 Enhanced Benefit Account................................................................................................... 3-21 Emergency Medicaid for Aliens ........................................................................................... 3-22 Family Planning Waiver Services ....................................................................................... 3-23 MediKids ............................................................................................................................. 3-25 Presumptively Eligible Pregnant Women (PEPW)............................................................... 3-26 Qualified Medicare Beneficiaries (QMBs) ........................................................................... 3-27 Special Low Income Medicare Beneficiaries (SLMB) and Qualifying Individuals I (QI1) .... 3-28 Special Coverage Categories .............................................................................................. 3-29 Institutional Care Program ................................................................................................... 3-29 Mary Brogan Breast and Cervical Cancer Program ............................................................ 3-31 Medically Needy Program .................................................................................................... 3-31 Presumptively Eligible Newborns (PEN) .............................................................................. 3-33 Unborn Activation Form ....................................................................................................... 3-34 Medical Assistance Referral Form ....................................................................................... 3-35

Chapter 4 - Medicare Crossover Policy

Medicare Coverage ................................................................................................................ 4-1 Medicare Crossover Claims ................................................................................................... 4-3 Participation in Medicare Crossovers .................................................................................... 4-5 General Crossover Reimbursement Policies ......................................................................... 4-7 Third Party Liability (TPL)....................................................................................................... 4-8 Medicare Crossover Reimbursement for CMS-1500 Billers ................................................ 4-11 Medicare Crossover Claims Filing for CMS-1500 Billers ..................................................... 4-13 Claims Resolution for the CMS-1500................................................................................... 4-18 Medicare Crossover Reimbursement for UB-04 Billers ....................................................... 4-20 Medicare Crossover Claims Filing for UB-04 Billers ............................................................ 4-25 Claims Resolution for the UB-04.......................................................................................... 4-32

Chapter 5 - Medicaid Abuse and Fraud

Oversight Agencies ............................................................................................................... 5-1 Provider Abuse....................................................................................................................... 5-3 Provider Fraud ....................................................................................................................... 5-3 Provider Responsibility........................................................................................................... 5-4 Administrative Sanctions........................................................................................................ 5-5 Recovery of Costs .................................................................................................................. 5-8 Prepayment Reviews ............................................................................................................. 5-9 Self Audits .............................................................................................................................. 5-9 Appeals on Medicaid Actions for Provider Abuse and Fraud .............................................. 5-10

Appendices

Appendix A ? Important Addresses and Telephone Numbers ................................................ A-1 Appendix B ? Glossary ........................................................................................................... B-1 Appendix C ? Medicaid Eligibility Codes on the FMMIS Recipient

Subsystem ........................................................................................................C-1 Appendix D ? Medicaid Out-of-State Prior-Authorization Form ..............................................D-1

Florida Medicaid Provider General Handbook

Overview Introduction Background

Legal Authority In This Chapter

INTRODUCTION TO THE HANDBOOK

This chapter introduces the format used for the Florida Medicaid handbooks and tells the reader how to use the handbooks.

There are three types of Florida Medicaid handbooks:

x Provider General Handbook describes the Florida Medicaid Program. x Coverage and Limitations Handbooks explain covered services, their

limits, who is eligible to receive them, and the fee schedules. x Reimbursement Handbooks describe how to complete and file claims for

reimbursement from Medicaid.

Exception: For Prescribed Drugs, the coverage and limitations handbook and the reimbursement handbook are combined into one.

The following federal and state laws govern Florida Medicaid:

x Title XIX of the Social Security Act; x Title 42 of the Code of Federal Regulations; x Chapter 409, Florida Statutes; x Chapter 59G, Florida Administrative Code.

This chapter contains:

TOPIC Handbook Use and Format Characteristics of the Handbook Handbook Updates

PAGE ii iii iii

July 2012

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