UPDATE: Hurricane Irma Provider Information (Last Updated: September 22, 2017)
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September 21, 2017, Instructions for Enrollment and Payment for Services Rendered During the Hurricane Irma Disaster
The purpose of this alert is to provide detail on how to implement the 9/8/17 provider alert, Guidance to All Providers Regarding Provision of Services During Hurricane Irma: This Guidance Applies for Both Fee-For-Service and Managed Care Providers.
The Agency for Health Care Administration (Agency) will ensure reimbursement for services provided in good faith to eligible Florida Medicaid recipients during the Hurricane Irma disaster grace period. The Agency’s Hurricane Irma disaster grace period is from 9/7/17 through 9/21/17.
Section I of this alert provides updated policy guidance and applies to services rendered through both the fee-for-service (FFS) delivery system and the Statewide Medicaid Managed Care (SMMC) program, unless otherwise stated.
Section II of this alert provides reimbursement/payment guidance and applies to services rendered in the FFS delivery system, unless otherwise specified.
Section I: Policy Guidance
Services Provided During the Disaster Grace Period (9/7/17 through 9/21/17)
Prior Authorization Requirements
- Florida Medicaid waived all prior authorization requirements for Medicaid services with dates of service during the disaster grace period.
Limits on Services
- Florida Medicaid waived limits on services (specifically related to frequency, duration, and scope) that were exceeded in order to maintain the health and safety of recipients for dates of service during the disaster grace period.
- Florida Medicaid lifted all limits on early prescription refills during the disaster grace period for maintenance medications, with the exception of controlled substances. The edits prohibiting early prescription refills will remain lifted until further notice by the Agency.
- To be reimbursed for services rendered to eligible Florida Medicaid recipients on the dates of service in the disaster grace period, providers not already enrolled in Florida Medicaid (out-of-state or in-state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at http://www.mymedicaid-florida.com.
Services Provided Outside of the Disaster Grace Period
- Florida Medicaid (fee-for-service and Medicaid health plans) may reimburse for services provided before the disaster grace period, on a case-by-case basis, if the service was necessary to maintain health and safety. Florida Medicaid will only approve instances in which early evacuations in parts of the state resulted in the recipient receiving care in a different region or out-of-state or if it was necessary for the recipient to refill a prescription early.
- For dates of service beginning 9/22/17, Florida Medicaid (fee-for-service and Medicaid health plans) will return to normal business operations as it relates to the coverage and reimbursement of Medicaid services, except as described below:
- Florida Medicaid will continue to reimburse for services furnished after the disaster grace period without prior authorization and without regard to service limitations or whether such services are provided by a current Medicaid enrolled provider in those instances where the provider and/or recipient could not comply with policy requirements because of ongoing storm-related impacts. Providers must have rendered services in good faith to maintain the recipient’s health and safety. Examples of such instances include:
- The provider still does not have access to the Internet or phone services as a result of continued power outages, therefore could not request prior authorization timely;
- The recipient continues to be displaced and must receive services in a different region of the state or out-of-state; or
- The recipient’s assigned primary care physician or specialist’s office remains closed due to the storm and urgent care is rendered at another provider’s location without prior authorization.
- Florida Medicaid will expedite authorization for new authorization requests submitted from September 22, 2017 through September 30, 2017, for durable medical equipment and supplies and home health services.
- Florida Medicaid will complete the reviews for expedited authorizations within forty-eight (48) hours after receipt of the request for service. Florida Medicaid may extend the timeframe for expedited authorization decisions by up to two (2) business days if the recipient or the provider requests an extension or if additional information is needed to process the request, and the extension is in the recipient’s interest.
Section II: Payment Guidance
The Agency and its Medicaid health plans will implement claims payment exceptions processes for any medically necessary services furnished during the disaster grace period that normally would have required prior authorization, that were rendered by a non-participating provider, or that exceeded normal policy limits for the service.
Providers that furnished services to Medicaid health plan enrollees should work directly with each plan on reimbursement protocols. The Agency is requiring that Medicaid health plans create a web page dedicated to providing detailed instructions to providers for how to seek reimbursement through each Medicaid health plan’s claims payment exceptions process. A direct link to each plan’s claims payment exceptions website will be located on the Agency’s website by September 26, 2017.
Providers that wish to receive payment for services rendered during and outside of the disaster grace period are required to be enrolled with Florida Medicaid or provisionally enrolled with Florida Medicaid prior to submitting claims. For services provided to recipients receiving services through the FFS delivery system, provisional providers should submit claims in accordance with the instructions located at: http://www.mymedicaid-florida.com.
Providers Currently Enrolled with Florida Medicaid
Providers that furnished services to recipients receiving services through the FFS delivery system must comply with the requirements below:
- For services provided during the disaster grace period, providers may submit electronic claims in accordance with normal HIPAA compliant transaction requirements if the service requires a prior authorization number, but prior authorization was not obtained.
- For services provided during the disaster grace period, providers may submit paper claims as described in the Agency’s exceptional claims process if service limitations exceeded those stated in the coverage policy or the respective fee schedule.
- For services provided outside of the disaster grace period because of storm-related impacts (See Section I of the alert), providers may submit paper claims as described in the Agency’s exceptional claims process.
- The Hurricane Irma request for exceptional claims processing form can be accessed through the following link: Hurricane Irma Request for Exceptional Claims Processing Form NEW
Reimbursement Rates (for services provided during the disaster grace period)
- Florida Medicaid will reimburse for services provided through the FFS delivery system in accordance with the rates established on the Medicaid fee schedules and the provider reimbursement rates/reimbursement methodologies published on the Agency’s web page. This applies to current enrolled providers and providers that complete the provisional enrollment process.
- The Agency’s web page includes links to the Diagnosis-Related Groups and Enhanced Ambulatory Patient Grouping System rate calculator, which provisionally-enrolled providers can utilize.
- Nursing facilities will receive reimbursement for applicable scenarios as detailed in Section 8.0 of the Florida Medicaid Nursing Facility Coverage Policy. For instances not detailed in the coverage policy, the nursing facility will receive the Florida Medicaid nursing facility statewide weighted average rate, which is $227.68 per day.
- The Medicaid health plans will reimburse participating network providers for services provided at the rates mutually agreed upon by the provider and the plan in their contract/agreement. The Medicaid health plans will reimburse non-participating providers (i.e., providers not already contracted with the Medicaid health plan), for services provided in accordance with the rates established on the Medicaid fee schedules and the provider reimbursement rates/reimbursement methodologies published on the Agency’s web page, unless otherwise mutually agreed upon by the provider and the Medicaid health plan.
Maintenance of Supporting Documentation
- Providers rendering services must maintain as much documentation as possible to help properly and timely adjudicate claims. Nothing precludes the Agency or its Medicaid health plans from conducting retrospective reviews to detect any fraud or abuse.
Agency’s Hurricane Irma Website
- Additional information for providers is located on the Agency’s website, http://www.ahca.myflorida.com. Click on the Hurricane banner at the top of the page for more information.
Medicaid Contact Center
Additional questions from providers may be directed to the Florida Medicaid Contact Center at 1-877-254-1055.