The purpose of this rule is to incorporate by reference the Florida Medicaid Provider Reimbursement Handbook, UB-04, March 2007. The Department of Health and Human Services, Centers for Medicare and Medicaid, replaced the UB-92 claim form with the ...

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO: RULE TITLE
59G-4.003: Medicaid Providers Who Bill on the UB-04
PURPOSE AND EFFECT: The purpose of this rule is to incorporate by reference the Florida Medicaid Provider Reimbursement Handbook, UB-04, March 2007. The Department of Health and Human Services, Centers for Medicare and Medicaid, replaced the UB-92 claim form with the UB-04 claim form effective March 2007. The handbook contains the instructions for the new claim form. The effect will be to incorporate by reference in rule the Florida Medicaid Provider Reimbursement Handbook, UB-04, March 2007.
SUBJECT AREA TO BE ADDRESSED: Medicaid Providers Who Bill on the UB-04.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.902, 409.905, 409.906, 409.907, 409.908, 409.912 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: Monday, April 2, 2007, 2:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building #3, Conference Room D, Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Catherine McGrath, Medicaid Services, 2727 Mahan Drive, Building 3, Mail Stop 20, Tallahassee, Florida 32308-5407, [phone], [e-mail]

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-4.003 Medicaid Providers Who Bill on the UB-04.

(1) All Medicaid providers and their billing agents who submit claims on behalf of an enrolled Medicaid provider who are required by their service-specific coverage and limitations handbook or other notification by the Medicaid Program to bill the Florida Medicaid Program on a paper UB-04 claim form for reimbursement of services performed on a Medicaid eligible recipient, must be in compliance with the provisions of the Florida Medicaid Provider Reimbursement Handbook, UB-04, March 2007, which is incorporated by reference. The handbook is available from the Medicaid fiscal agent’s website at http://floridamedicaid.acs-inc.com. Click on Provider Support, and then on Handbooks. Paper copies of the handbook may be obtained by calling the Medicaid fiscal agent at [phone].

(2) The following forms that are included in the Florida Medicaid Provider Reimbursement Handbook, UB-04, are incorporated by reference: in Chapter 1, the UB-04 CMS-1450 (03-07), one page double-sided; and in Chapter 2, the State of Florida, Florida Medicaid Authorization Request, PA01 04/2002, one page; Medically Needy Billing Authorization, CF-ES 2902, June 2003, one page; State of Florida, Sterilization Consent Form, SCF 7/94, one page; State of Florida, Hysterectomy Acknowledgment Form, HAF 07/1999, one page; State of Florida, Exception to Hysterectomy Acknowledgment Requirement, ETA 07/2001, one page; State of Florida, Abortion Certification Form, AHCA-Med Serv Form 011, August 2001, one page. All the forms are available from the Medicaid fiscal agent by calling [phone] or from its website at http://floridamedicaid.acs-inc.com. Click on Provider Support, and then on Medicaid Forms.

Specific Authority 409.919 FS. Law Implemented 409.902, 409.905, 409.906, 409.907, 409.908, 409.912 FS. History–New __________.