Florida Medicaid

Florida Medicaid

Provider Reimbursement Handbook, CMS-1500

Agency for Health Care Administration

CHARLIE CRIST GOVERNOR

October 13, 2008

HOLLY BENSON SECRETARY

Dear Medicaid Provider:

Enclosed please find the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, effective July 2008. We added the time limit for submission of a claim to Chapter 1. We also added a new Chapter 3, which contains additional filing requirements, such as prior authorizations, authorization for inpatient hospital admissions, and special forms that must be submitted with claims for certain types of services. Please use this new handbook in place of the advance draft that was posted on the Medicaid fiscal agent's website on May 29, 2008.

Please contact your area Medicaid office if you have any questions. The area Medicaid offices' phone numbers and addresses are available on the Agency's website at . Click on Medicaid, and then on Area Offices. They are also listed in Appendix C of the Florida Medicaid Provider General Handbook. All the Medicaid handbooks are available on EDS' Web Portal at . Click on Public Information for Providers, then on Provider Support, and then on Provider Handbooks.

We appreciate the services that you provide to Florida's Medicaid recipients.

Sincerely,

Beth Kidder Chief, Bureau of Medicaid Services

2727 Mahan Drive, MS#20 Tallahassee, Florida 32308

Visit AHCA online at

UPDATE LOG MEDICAID PROVIDER REIMBURSEMENT HANDBOOK

CMS-1500

How to Use the Update Log

Introduction

The current Medicaid provider handbooks are posted on the Medicaid fiscal agent's Web Portal at . Click on Public Information for Providers, then on Provider Support, and then on 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 No. is the month and year that the update was issued.

Effective Date is the date that the update is effective.

Instructions

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

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

UPDATE NO. New Handbook May2001 ? Update Pages Errata May2001 Update Page Oct2003 ? New Handbook Feb2006--Revised Handbook Jan2007--Replacement Pages Nov2007--Replacement Pages Jul2008--Revised Handbook

EFFECTIVE DATE July 1999 May 2001 May 2001 October 2003 February 2006 January 2007 November 2007 July 2008

FLORIDA MEDICAID PROVIDER REIMBURSEMENT HANDBOOK

CMS-1500

Table of Contents

Chapter/Topic

Page

Introduction

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

Chapter 1 ? Completing the Claim Form

Providers Who Bill on the CMS-1500..................................................................1-2 Time Limit for Submission of a Claim ................................................................. 1-4 Basic Guidelines for Completing a Claim Form .................................................. 1-9 How to Complete the CMS-1500 Claim Form...................................................1-10 Place of Service Codes (POS) .......................................................................... 1-37 Sample of a Completed CMS-1500 Claim Form...............................................1-41 Claims Submission Checklist ............................................................................ 1-45 Claims Mailing Checklist ................................................................................... 1-46 Where to Send Claim Forms.............................................................................1-46 Electronic Claims Submission...........................................................................1-47

Chapter 2 ? Claims Processing

Claims Processing .............................................................................................. 2-1 Remittance Advice (RA) ...................................................................................... 2-2 How to Read the Remittance Advice................................................................... 2-6 Sample Remittance Advice ................................................................................. 2-7 How to Resubmit a Denied Claim ..................................................................... 2-18 Resolving an Incorrect Payment ....................................................................... 2-19 How to File a Void Request on a Paper Claim .................................................. 2-21 Sample Void Request--CMS-1500 Claim Form ............................................... 2-24 How to File an Adjustment Request on a Paper Claim ..................................... 2-25 Sample Adjustment Request CMS-1500 Claim Form.......................................2-28 Identifying Adjustments and Voids on the Remittance Advice .......................... 2-29 Billing Medicaid When There is a Third Party Liability Discount .......................2-30

Contract

Chapter 3 ? Additional Filing Requirements

Prior Authorization Requirements ....................................................................... 3-2 Medicaid Authorization Request Form ................................................................ 3-9 Sample Completed Medicaid Authorization Request Form, PA 01...................3-13 Checklist for the Medicaid Authorization Request Form ................................... 3-14 Prior Authorization for Medically Needy Recipients...........................................3-15 Prior Authorization for Out-of-State Services .................................................... 3-17 Authorization for Inpatient Hospital Admissions ................................................ 3-19 Authorization for Inpatient Psychiatric and Substance Abuse Services ............ 3-26

Chapter 3 ? Additional Filing Requirements, continued

Authorization for Organ Transplants ................................................................. 3-29 Special Billing for Medically Needy Recipients .................................................. 3-31 Out of State Claims ........................................................................................... 3-35 Consent For Sterilization Form..........................................................................3-36 Hysterectomy Acknowledgment Form .............................................................. 3-45 Exception to Hysterectomy Acknowledgment Requirement Form .................... 3-49 Abortion Certification Form ............................................................................... 3-53 Florida's Healthy Start Prenatal Risk Screening Instrument ............................. 3-56

Appendices

Appendix A: Internal Control Number Region Codes........................................ A-1

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