AGENCY FOR HEALTH CARE ADMINISTRATION
MedicaidRULE NO.: RULE TITLE:
59G-5.020Provider RequirementsNOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 38, No. 33, August 17, 2012 issue of the Florida Administrative Register.
The following changes have been made to the proposed rule.
(2) The following forms are incorporated by reference: Medicare Part C-Medicaid CMS-1500 Crossover Invoice AHCA Form 5000-3527, June 2012; Medicare Part C-Medicaid UB-04 Crossover Invoice AHCA Form 5000-3528, June 2012; and Medicaid Out-of-State Prior-Authorization Request Form AHCA Med Serv Form 2000-0016. The forms are available from the fiscal agent’s Web site at www. mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Forms. Paper copies of the forms may be obtained by calling the Provider Services Contact Center at 1(800)289-7799 and selecting Option 7.
(2) The following forms that are included in the Florida Medicaid Provider General Handbook are incorporated by reference. In Chapter 3, Temporary Emergency Medicaid Identification Card, July 2008; CF-ES 2681, Notice and Proof of Presumptive Eligibility for Medicaid for Pregnant Women, Feb 2003; CF-ES Form 2014, Authorization for Medicaid/Medikids Eligibility, Feb 2003; AHCA Form 5240-006, Unborn Activation Form, January 2007; CF-ES 2039, Medical Assistance Referral, Sep 2002. In Chapter 4, AHCA-Med Serv 038, Crossover with TPL Claim and/or Adjustment Form, July 2008; AHCA Form 5000-3527, Medicare Part C-Medicaid CMS-1500 Crossover Invoice, June 2012; AHCA Form 5000-3528, Medicare Part C-Medicaid UB-04 Crossover Invoice, June 2012. Appendix D, AHCA Med Serv Form 2000-0016, Medicaid Out-of-State Prior-Authorization Request Form, January 2012. The CF-ES forms are available from the Department of Children and Family Services. The other forms are available from the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Forms. Paper copies of the forms may be obtained by calling the Provider Services Contact Center at 1-800-289-7799 and selecting Option 7.
The following changes have been made to the Florida Medicaid Provider General Handbook, July 2012.
Page 2-21 Crossover-Only Provider Enrollment Requirements
The section now reads:
Entities may enroll as a Medicare Crossover-Only provider for payment and claim processing purposes only. See 409.907(5)(d), F.S.
The following documentation must be submitted with the Medicaid provider enrollment application:
1.Medicare Approval Letter;
2.An Explanation of Medicare Benefits (EOMB) showing a paid claim with a date of service within 30 days prior to the application submission;
3.A letter on company letterhead, signed by an officer authorized to bind the company, attesting that the provider meets all Florida Medicaid provider enrollment criteria including requirements specific to its provider type, if Florida Medicaid enrolls such providers. The provider must also acknowledge that Florida Medicaid may conduct on-site reviews prior to approving the crossover provider identification number; and
4.Completed fingerprint cards.
Providers will be required to reenroll every three years.
Note: See How to Obtain Enrollment Forms in Chapter 2 of this handbook for information on how to obtain fingerprint cards and the Criminal History Check section of this handbook.
Page 2-21 Crossover-Only Durable Medical Equipment Provider
The section now reads:
Durable medical equipment (DME) entities, including medical supply providers, may enroll as a Medicare Crossover-Only provider for payment and claim processing purposes only. These entities are subject to all the Crossover-Only Provider Enrollment Requirements above.
In addition, DME entities must submit proof of current accreditation from a Florida Medicaid approved accrediting organization.
Medicare Crossover-Only DME providers are exempt from the requirement to maintain an in-state business location.
Note: See the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage and Limitations Handbook to review approved accrediting organizations.
Page 2-22 Crossover-Only Provider Enrollment Exclusions
The section now reads:
The following entities are excluded from enrollment as a Medicare Crossover-Only provider:
•Entities that (1) are currently sanctioned by Florida Medicaid, (2) have been involuntarily terminated by Florida Medicaid within the last three years, except for reason of inactivity, or (3) have voluntarily terminated from Florida Medicaid without a repayment agreement, where applicable; and
•Entities that (1) are currently sanctioned by Medicare, (2) have been involuntarily terminated by Medicare within the last three years, or (3) have voluntarily terminated from Medicare without a repayment agreement, where applicable.
Page 2-24 Exemption for Board Members
The section now reads:
Per section 409.907(8)(a), board members of a not-for-profit corporation or organization are exempt from the criminal history check if they meet all of the following criteria:
•Serve solely in a voluntary capacity;
•Do not regularly take part in the day-to-day operational decisions of the corporation or organization;
•Receive no remuneration from the corporation or organization for their service on the board of directors;
•Have no financial interest in the corporation or organization; and
•Have no family members with financial interest in the corporation or organization
Page 2-25 Exemption Forms for Boards
The section now reads:
To obtain the exemption, the corporation or organization must submit a Non-Profit Organization Volunteer Board Member Exemption from Medicaid Criminal History Checks along with a list of the board members’ names and social security numbers. The Non-Profit Organization Volunteer Board Member Exemption from Medicaid Criminal History Checks is an attachment to the Florida Medicaid Provider Enrollment Application, AHCA Form 2200-0003, F.A.C.
Note: A Non-Profit Organization Volunteer Board Member Exemption from Medicaid Criminal History Checks may be obtained from the Medicaid fiscal agent by calling Provider Enrollment at 800-289-7799 and selecting Option 4 or by downloading the form from the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Enrollment.
Page 2-25 Exemption for Providers
The section now reads:
The following providers are exempt from the criminal history check:
•Hospitals licensed under Chapter 395, Florida Statutes. (This exemption does not apply to the physicians’ groups, laboratories, pharmacies, or other non-institutional providers that are not licensed under Chapter 395, but are owned by or affiliated with the hospital);
•Nursing facilities, hospices, assisted living facilities, and adult family care homes licensed under Chapter 400, Florida Statutes. (This exemption does not apply to the physicians’ groups, laboratories, pharmacies, durable medical equipment companies or other non-institutional providers not licensed under Chapter 400, but are owned by or affiliated with the nursing facilities, hospices and assisted living facilities);
•School districts as an entity. (This exemption does not apply to instructional and non-instructional personnel who are hired or contracted to fill positions that require direct contact with students in any district school system or university lab school. Upon employment or engagement to provide services, schools must undergo background screening as required under section 1012.465, F.S., or section 1012.56, F.S., whichever is applicable.);
•Units of local government. (This exemption does not apply to non-governmental providers and entities that contract with the local government to provide Medicaid services. The contracted entities are responsible for the cost of the criminal history checks for all applicable staff and management); and
•Any business that derives more than 50 percent of its revenue from the sale of goods to the final consumer AND either the business or its controlling parent is required to file a form 10-K or similar statement with the Securities and Exchange Commission OR the business has a net worth of $50 million or more. (This exception is designed primarily to exclude large pharmaceutical companies. The business must submit its annual report including audited financial statements or 10-K Form with the exemption request.)
Page 2-26 Exemption for DCF License
The section is deleted.
Page 2-26 Exemption for Physicians, RNs, and ARNPs
The section is deleted.
Page 2-27 Criminal History Check by Other Agencies
The section now reads:
Medicaid accepts proof of level 2 criminal history checks conducted by other Florida agencies or departments that have been completed in compliance with Chapter 435, F.S., and section 408.809, F.S., within 12 months of receipt of the application.
The provider must submit a letter or official form from the agency that conducted the criminal history check with the Enrollment Application. The letter or form must specify the applicant’s name, Social Security Number, date the criminal history check was completed, the level of the screening and the results.
Medicaid Provider Enrollment will review the information and approve or deny the application.
Page 2-30 Durable Medical Equipment Providers
The section now reads:
In accordance with s.409.912(45)(b), F.S., effective January 1, 2009, one $50,000 bond is required for each durable medical equipment (DME) and medical supply provider location, up to a maximum of five (5) bonds statewide or an aggregate bond of $250,000 statewide as identified per Federal Employer Identification Number (F.E.I.N.). Providers who qualify for a statewide or an aggregate bond must identify all their locations in any Medicaid DME and medical supply provider enrollment application or bond renewal.
A surety bond must be submitted as part of the Medicaid DME and medical supply provider enrollment application. Each provider location’s surety bond must be renewed annually and the provider must submit proof of renewal, even if the original bond is a continuous bond.
Page 2-30 Durable Medical Equipment Provider Surety Bond Exemptions
The section now reads:
In accordance with s. 409.912(45)(b), F.S., effective January 1, 2009, a DME and medical supply business is exempt from surety bond requirements if the DME and medical supply business’ physical location is:
•Owned and operated by a government entity; or
•Operated by and within a pharmacy that is currently enrolled as a Medicaid pharmacy provider; or
•Medicaid-enrolled orthopedic physician’s groups that are more than 50 percent owned by physicians, providing only orthotic and prosthetic devices, and has been an active Medicaid provider in good standing; or
•A licensed orthotist or prosthetist that provides only orthotic or prosthetic devices as a Medicaid durable medical equipment provider.
Page 2-34 Who Must Have a Site Visit
The section now reads:
Per 42 CFR 455.432, the state Medicaid agency must conduct pre-enrollment and post-enrollment site visits of providers who are designated as “moderate” or “high” categorical risks to the Medicaid program. The purpose of the site visit will be to verify that the information submitted to the state Medicaid agency is accurate and to determine compliance with federal and state enrollment requriements.
In accordance with this regulation, on-site reviews are required for enrollment of the following provider types:
•Community Mental Health;
•Durable Medical Equipment (DME);
•Physician groups if more than 50 percent of the practice is owned by non-physicians;
•Non-emergency transport;
•Taxicab companies; and
•Multi-load private transport.
At AHCA’s discretion, site visits may be required for other provider types.
Page 2-44 Out-of-State Enrollment Procedures
The section now reads:
To enroll, the out-of-state provider must submit the following documents to the fiscal agent:
•Florida Medicaid Out-of-State Provider Enrollment Application, Form PE-OOSPEA-March 1, 2008;
•The appropriate Florida Medicaid Provider Agreement, either Institutional or Non-Institutional;
•Copy of professional license;
•Completed claim form; and
•Documentation that the claim meets one of the criteria listed above.
An out-of-state provider is enrolled retroactively for the dates on which it provided eligible services for Medicaid payment.
Note: The Florida Medicaid Out-of-State Provider Enrollment Application, Form PE-OOSPEA, may be obtained from the Medicaid fiscal agent by calling the Provider Contact Center at 800-289-7799 and selecting Option 4. The form is also available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, then Enrollment, and then Out-of-State Enrollment.
Note: See Non-Institutional Provider Enrollment and Institutional Provider Enrollment in this chapter to determine which Florida Medicaid Provider Agreement is appropriate for the out-of-state provider’s type.
Page 2-53 Procedures for Reporting a Change of Address, continued
The section now reads:
If the provider is changing the financial institution where electronic funds transfers are received, the provider must also complete and submit a new Electronic Funds Transfer Authorization. The Electronic Funds Transfer Authorization form is an attachment to the Florida Medicaid Provider Enrollment Application, AHCA Form 2200-0003.
Note: Electronic Funds Transfer Authorization may be obtained from the Medicaid fiscal agent by calling Provider Enrollment at 800-289-7799 and selecting Option 4 or by downloading the form from the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Enrollment.
Page 2-54 Definition of Change of Ownership
The section now reads:
Section 409.901(5), F.S., defines a change of ownership as follows:
“(a) An event in which the provider ownership changes to a different individual entity as evidenced by a change in federal employer identification number or taxpayer identification number;
(b) An event in which 51 percent or more of the ownership, shares, membership, or controlling interest of a provider is in any manner transferred or otherwise assigned. This paragraph does not apply to a licensee that is publicly traded on a recognized stock exchange; or
(c) When the provider is licensed or registered by the agency, an event considered a change of ownership for licensure as defined in section 408.803.”
A change solely in the management company or board of directors is not a change of ownership.
Page 2-67 Requirements
The section now reads:
Chapter 409.912(37)(a)5., Florida Statutes, requires Medicaid-participating prescribers or prescribers who write prescriptions for Medicaid recipients to use a standardized counterfeit-proof prescription blank when writing prescriptions for Medicaid recipients.
Medical practitioners (prescribers) must obtain and use a counterfeit-proof prescription blank or prescription order form produced by a vendor approved by AHCA when writing hard copy prescription(s) for Medicaid recipients for any covered service under the Florida Medicaid Prescribed Drug Services Program. Prescriptions presented via
other modes of transmission, e.g., facsimile, electronic-prescribing, telephone, are exempt from this requirement.
A uniform layout, format, or style is not required when a vendor or vendor’s software produces the blank or printed prescription. Prescribers may customize the layout in accordance with applicable federal and state laws and regulations. AHCA requires that all vendors ensure the blanks or printed prescriptions produced meet the minimum security feature specifications required and include a tracking identifier printed on the front of the blank or printed prescription. The minimum security features include the following: the background color of the blank or printed prescription must be blue or green and resist reproduction, the blank or printed prescription must resist erasures and alterations, and the word “void” or “illegal” must appear on a photocopy of the blank or prescription. The security features must be listed on the blank or printed prescription.
Page 2-68 Approved Vendors
The section now reads:
AHCA approves the vendors that may manufacture and distribute the counterfeit-proof prescription blanks. AHCA also approves vendors that market a software program that produces in conjunction with a production system, a hard copy printed prescription. The prescription blanks or printed prescription documents must meet AHCA counterfeit-proof specifications as detailed above in the Requirements information block.
The vendors must comply with vendor requirements established by AHCA as follows:
•They are accountable for the prescription blanks or documents produced, stored, and the prescription blanks’ or documents’ delivery.
•They are responsible for appropriate safeguards to protect against unauthorized access to the blanks or software program and production systems used for prescribing.
•They must maintain secure storage locations and deliver blanks or software programs only to authorized licensed medical practitioners.
•The software program and production system must have appropriate safeguards to allow access and use only by authorized licensed medical practitioners.
•Upon request, the vendors must provide AHCA with any records relevant to the production, security, and delivery of the prescription blanks or software program and production system outputs.
Approved vendors are assigned a unique alpha prefix identifier that is the first part of a tracking identifier that is required to be printed on the front of the blank or printed prescription.
A list of approved vendors can be found on the fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Pharmacy, and then Counterfeit-proof Prescriptions. Complaints about a vendor’s products may be filed with Medicaid Program Integrity.
Page 3-29 Institutional Care Program
The section titled “Description” now reads as follows:
Medicaid reimburses institutional care services for Medicaid-eligible residents who meet Medicaid Institutional Care Program (ICP) eligibility requirements described in the Eligibility Requirements section below.
Medicaid covers the services listed in the Nursing Facility, Intermediate Care Facility for the Developmentally Disabled (ICF/DD), and State Mental Hospital Coverage and Limitations Handbooks for recipients who meet the eligibility requirements defined below.
Note: The Coverage and Limitations Handbooks are incorporated by reference in the Medicaid Services’ Rule Division 59G, F.A.C. They are available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.
Page 4-38 Medicaid Part C Crossover Claim Form for CMS 1500 Billers
The following has been added to the form:
Incorporated by reference in 59G-5.020, F.A.C.
Page 4-39 Medicaid Part C Crossover claim Form for UB-04 Billers
The following has been added to the form:
Incorporated by reference in 59G-5.020, F.A.C.
Page 5-10 Self Audits
The section now reads:
A provider has an obligation to ensure that claims or encounter claims submitted to the Medicaid program are true and accurate. Section 409.913, F.S., obligates AHCA to impose a sanction on providers when AHCA has discovered certain specified violations of Medicaid laws, including the laws governing the provider’s profession. However, it also authorizes AHCA to institute amnesty programs wherein Medicaid providers may repay an overpayment without the imposition of sanctions.
If, as a result of a self-audit, a provider determines that a claim or encounter claim was paid by the Medicaid program in error, the provider has the opportunity to report the violation and repay the overpayment to AHCA without resulting in the imposition of sanctions.
Note: For information on sanctions, see 59G-9.070, F.A.C.
Appendix B, Page B-6
A new section titled “Encounter Claim” is added to the Appendix B Glossary and is defined as follows:
Encounter Claim: An individual transaction that contains a record of diagnostic or treatment procedures or other medical or allied care provided to a health plan’s enrollees, excluding services paid by Medicaid on a fee-for-service basis. An “encounter” is an interaction between a patient and provider (health plan, rendering physician, pharmacy, lab, etc.) who delivers services or is professionally responsible for services delivered to a patient.
A new section titled “Encounter Data” is added to the Appendix B Glossary and is defined as follows:
Encounter Data: A record of diagnostic or treatment procedures or other medical or allied care provided to a health plan’s enrollees, excluding services paid by Medicaid on a fee-for-service basis.
Page D-2 Medicaid Out-of-State Prior-Authorization Form
The following has been added to the form:
Incorporated by reference in Rule 59G-5.020, F.A.C., January 2012
