AGENCY FOR HEALTH CARE ADMINISTRATION
RULE NO.:RULE TITLE:
59G-1.060Enrollment Policy
NOTICE 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. 45 No. 88, May 6, 2019 issue of the Florida Administrative Register.
Rule text has been changed as follows:
59G-1.060 Provider Enrollment Policy.
(1) through (2), No change.
(3) The following forms are incorporated by reference and available on the Florida Medicaid Web portal at http://portal.flmmis.com/flpublic, and as follows:
(a) through (b), No change.
(c) Certification of Funds, AHCA Form 5000-3532, May 2014, http://www.flrules.org/Gateway/reference.asp?No=Ref-_______.
(d) through (g) redesignated (c) through (f), No change.
(h) Florida Medicaid Electronic Funds Transfer (EFT) Authorization Agreement, AHCA Form 5000-1063, _______, http://www.flrules.org/Gateway/reference.asp?No=Ref-_____.
(i) Florida Medicaid National Provider Identifier (NPI) Registration, AHCA Form 5000-1060, _______, http://www.flrules.org/Gateway/reference.asp?No=Ref-_____.
(j) Group Membership Authorization Form, AHCA Form 5000-1061, _______,
http://www.flrules.org/Gateway/reference.asp?No=Ref-_____.
(k) through (w) redesignated (g) through (s)., No change.
All references to forms within the rule text have been updated with the form’s effective date, if applicable.
The Florida Medicaid Provider Enrollment Policy has been updated as follows:
Section 1.0, Introduction, No change.
Section 2, General Enrollment Policy, is updated as follows:
Section 2.1, Enrollment Application Process, first paragraph now reads:
Providers must submit an enrollment application using the Online Provider Enrollment Wizard (Wizard), incorporated by reference in Rule 59G-1.060, F.A.C., and available on the Florida Medicaid Web portal at http://portal.flmmis.com/flpublic.
Sections 2.2 through 2.3, No change.
Section 2.4, Application Types, is updated as follows:
Section 2.4.1 Group Membership now reads:
Group membership authorization is required when forming, joining, or separating from a group. Providers must submit a Group Membership Authorization, AHCA Form 5000-1061, __________, incorporated by reference, and available at http://portal.flmmis.com when joining a group, or when separating from a group.
Sections 2.5 through 2.15, No change.
Section 3.0, Enrollment Application – Specific Requirements, is updated as follows:
Section 3.1, No change.
Section 3.2 Tax Identification Numbers, second paragraph now reads:
Sole proprietors and sole proprietors enrolling as a member of a group must enroll with the provider’s Social Security Number. Florida Medicaid is authorized to collect this information in accordance with section 1902(a)(78) of the Social Security Act.
Sections 3.3 through 3.8, No change.
Add section 3.9 Florida Medicaid Electronic Funds Transfer Authorization, as follows:
Providers must submit a bank letter or voided check or deposit slip to receive direct reimbursement from Florida Medicaid.
Sections 4.0 through 8.0, No change.
Section 9.0 Appendices, is updated as follows:
Sections 9.1 through 9.2, No change.
Section 9.3, Appendix C: General Document Requirements, now reads:
Provider Type, All Provider Types, the following language is removed from the table:
Fully Enrolled Required Documents
Florida Medicaid Electronic Funds Transfer Authorization Agreement, AHCA Form 5000-1063,
incorporated by reference (with bank letter or voided check/deposit slip for providers who
receive direct reimbursement from Florida Medicaid)
Florida Medicaid National Provider Identifier (NPI) Registration, AHCA Form 5000-1060, _______, incorporated by reference (if required in accordance with 45 CFR Part 162)
Additional Documents for Sole Proprietor Enrolling as a Member of a Group or Group
Group Membership Authorization, AHCA Form 5000-1061, incorporated by reference
(applications must include a signed authorization for each member of the group-not required for limited or
ORP enrollment)
Limited Enrolled and Ordering or Referring Providers (ORPs) Required Documents
Limited enrolled providers must provide the documents listed above.
Exception: Limited enrolled providers and ORPs are not required to submit the Florida Medicaid Electronic
Funds Transfer Authorization Agreement, AHCA Form 5000-1063, incorporated by
reference.
Section 9.4, Appendix D, Provider Specific Documents, has been changed as follows:
All references to forms within the Policy, including the Appendices have been updated with the applicable form’s effective date, and clarification that the referenced form is incorporated by reference in Rule 59G-1.060, F.A.C.
Section 9.5, Appendix E, Provider Specific Documents.
The following change has been made to the Table:
Provider Type Code 39, Provider Type Description Behavior Analysis (Groups only), Health Care Clinic License or Proof of Exemption Requirement Date December July 1, 2020.
