1(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 CMS-1500 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, CMS-1500, July 2008, which is incorporated by reference. The handbook is available from the Medicaid fiscal agent’s Web Portal at http://mymedicaid-florida.com. Click on Public Information for Providers, then on Provider Support, and then on Provider Handbooks. Paper copies of the handbook may be obtained by calling the Provider Contact Center at 1(800) 289-7799 and selecting Option 7.
130(2) The following forms that are included in the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, are incorporated by reference: in Chapter 1, the CMS-1500 Claim Form, Approved OMB-0938-0999 Form CMS-1500 (08-05), one page double-sided; and in Chapter 3, the Florida’s Healthy Start Prenatal Risk Screening Instrument, DH 3134, 2/01, one page; State of Florida, Florida Medicaid Authorization Request, PA01 07/08, one page; Medically Needy Billing Authorization, DF-ES 2902, June 2003, one page; Consent For Sterilizatión, HHS-687 (11/2006), doublesided; Consentimiento Para La Esterilizacion, HHS-687-1 (11/2006), doublesided; State of Florida, Hysterectomy Acknowledgment Form, HAF 07/1999, one page; State of Florida, Exception to Hysterectomy Acknowledgment Requirement, ETA 07/2008, one page; State of Florida, Abortion Certification Form, AHCA-Med Serv Form 011, August 2001, one page. All the forms except for the Healthy Start Prenatal Risk Screening Instrument are available from the Medicaid fiscal agent by calling the Provider Contact Center at 1(800) 289-7799 and selecting Option 7 or from its Web Portal at http://mymedicaid-florida.com. Click on Public Information for Providers, then on Provider Support, and then on Forms. The Healthy Start Prenatal Risk Screening Instrument is available from the local County Health Department.
319Rulemaking Authority 321409.919 FS. 323Law Implemented 325409.902, 326409.905, 327409.906, 328409.907, 329409.908, 330409.912 FS. 332History–New 10-1-03, Amended 7-2-06, Amended 3-7-07, 4-9-08, 12-3-08.
