59G-5.110. Claims Payment

(1) Purpose. This rule describes the circumstances when the Agency for Health Care Administration (AHCA) may directly reimburse eligible Florida Medicaid recipients; how AHCA reimburses recipients; and documentation requirements for direct reimbursement.

(2) Determination Criteria. Florida Medicaid recipients may be eligible for direct reimbursement if:

(a) Medical goods and services were paid for by the recipient or a person legally responsible for their bills from the date of an erroneous denial or termination of Florida Medicaid eligibility to the date of a reversal of the unfavorable eligibility determination.

(b) The goods and services were medically necessary as defined in Rule 59G-1.010, Florida Administrative Code (F.A.C.); rendered by a provider that is qualified to perform the service including meeting any applicable certification or licensure requirements (the provider is not required to be enrolled or registered as a Florida Medicaid provider); and covered by Florida Medicaid for the recipient’s eligibility group on the date of service.

(c) Reimbursement for the medical goods or services is not available through any third-party payer on the date of service for which direct reimbursement is requested.

(3) Reimbursement Process. Recipients must submit direct reimbursement requests to AHCA within 12 months of the date of the reversal of the unfavorable eligibility determination described in paragraph (2)(a).

(a) The reimbursement request must include evidence of all out-of-pocket expenses paid to the provider, validated through receipts submitted by the recipient to: Agency for Health Care Administration, 2727 Mahan Drive, MS #58, Tallahassee, FL 32308.

(b) The Agency for Health Care Administration will send a Florida Medicaid Direct Reimbursement Recipient Information Request, AHCA Form 5240-0002, June 2016, incorporated by reference and available on the AHCA website at http://ahca.myflorida.com/Medicaid/review/index.shtml, or at http://www.flrules.org/Gateway/reference.asp?No=Ref-06750, to recipients if more information is required to determine their eligibility for direct reimbursement. Recipients must complete and return the signed form in accordance with the instructions provided on the form.

(c) The Agency for Health Care Administration will send a Florida Medicaid Direct Reimbursement Provider Information Request, AHCA Form 5240-0003, June 2016, incorporated by reference and available on the AHCA website at http://ahca.myflorida.com/Medicaid/review/index.shtml, or at http://www.flrules.org/Gateway/reference.asp?No=Ref-06750, if more information is needed from the provider to determine recipient eligibility for direct reimbursement. Providers must complete and return the signed form in accordance with the instructions provided on the form.

(4) Recipient Notification. The Agency for Health Care Administration will send reimbursement directly to the recipient in the amount the recipient paid to the provider. If AHCA determines that the expenses do not qualify for reimbursement, the recipient will be notified in writing after all information has been reviewed.

(5) Fair Hearing. The recipient has the right to request a Medicaid fair hearing if notified that reimbursement in full or in part is not approved. A request for a fair hearing must be made within 90 days from the date the notification is mailed to the recipient. The fair hearing may be requested by calling the Medicaid Helpline at 1(877)254-1055 or by contacting the Department of Children and Families Office of Appeal Hearings at [e-mail].

Rulemaking Authority 409.919 FS. Law Implemented 409.902 FS. History–New 9-22-93, Formerly 10P-5.110, Amended 5-9-99, 6-2-16.