The purpose of the amendment to Rule 59G-1.045 is to update forms incorporated by reference within the rule, and to incorporate by reference additional forms specified throughout Florida Medicaid rules.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-1.045Medicaid Forms

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-1.045, F.A.C. is to update forms incorporated by reference within the rule, and to incorporate by reference additional forms specified throughout Florida Medicaid rules.

SUBJECT AREA TO BE ADDRESSED: Medicaid Forms.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.902, 409.905(8), 409.912 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: January 29, 2016, 1:30 p.m. ‒ 2:30 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Laura Risech. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Laura Risech, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Comments will be received until 5:00 p.m., on February 1, 2016.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-1.045 Medicaid Forms.

(1) The following forms are incorporated by reference and are used either by other state agencies or providers enrolled in or registered with the Florida Medicaid program.

(2) The forms are available from the Florida Medicaid fiscal agent’s Web site at http://portal.flmmis.com/flpublic.

(a) Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form, AHCA Form 5000-3008, _________October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05826

(b) Pre-Admission Screen and Resident Review (PASRR) Level I Screen for Serious Mental Illness

(SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A, _________ October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05827

(c) Pre-Admission Screening and Resident Review (PASRR) Resident Review (RR) – Evaluation Request for a Significant Change for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A1,___________ October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05828

(d) Abortion Certification Form, AHCA MedServ Form 011, August 2011

(e) Appointment of Representation Form, AHCA Med-Serv Form 017, August 2007

(f) Authorization for the Use and Disclosure of Protected Health Information Form, AHCA Med-Serv Form 018

(g) Crossover with TPL Claim and/or Adjustment Form, AHCA MedServ Form 038, July 2008.

(h) Exception to Hysterectomy Acknowledgment Form, HAF 07/1999.

(i) Florida Medicaid Direct Reimbursement Provider Information Request, AHCA Form________,

___________

(j) Florida Medicaid Direct Reimbursement Recipient Information Request, AHCA Form_________,

___________

(k) Florida Medicaid Facility Utilization Review Plan, _______,_______.

(l) Florida Medicaid Orthodontic Initial Assessment Form, AHCA MedServ Form 013, January 2006.

(m) Hysterectomy Acknowledgment Form, HAF 07/1999.

(n) Medicaid Behavior Management Report, AHCA MedServ Form 012, January 2007.

(o) Parent or Legal Guardian Medical Limitations, AHCA Form 5000-3501, Revised February 2013.

(p) Parent or Legal Guardian School Schedule, AHCA Form 5000-3505, Revised October 2014.

(q) Parent or Legal Guardian Statement of Work Schedule, AHCA Form 5000-3504, Revised February 2013.

(r) Parent or Legal Guardian Work Schedule, AHCA Form 5000-3503, Revised February 2013.

(s) State of Florida Medicare Part C – Medicaid CMS-1500 Crossover Invoice, 5000-3527, June 2012.

(t) State of Florida Medicare Part C – Medicaid UB-04 Crossover Invoice, 5000-0026, June 2012.

(u) Unborn Activation Form, 5240-006, January 2007.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905(8), 409.912 FS. History–New 9-28-15, Amended_______.