Provider Enrollment

Provider Enrollment is comprised of three business teams, Plan and Provider Enrollment and Outreach, Provider Eligibility and Compliance, and Provider Business Module Management.

These teams provide coordination of provider enrollment functions, provider data maintenance, outreach, education, and issue resolution to providers, the Medicaid managed care plans, the Medicaid Regional Offices, and program operating partners at the Department of Health and the Agency for Persons with Disabilities.

Plan and Provider Enrollment and Outreach

Responsible for assisting plans and providers with the provider enrollment process, both initial and renewal; submitting provider maintenance to the Medicaid fiscal agent; receiving, tracking, and monitoring escalated issues, legislative requests, and public records requests; performing onsite reviews; coordinating and delivering plan and provider trainings related to provider enrollment; providing support for new plan enrollments under SMMC procurement, and coordinating with external agencies, including APO and DOH, regarding provider enrollment.

Provider Eligibility and Compliance

Responsible for ensuring the continued eligibility of enrolled providers through research and validation of providers who are excluded from participation in Medicare, Medicaid, or other federally-funded programs; documenting justifications for exclusions from Florida Medicaid; coordinating with Medicaid Program Integrity and the OGC regarding referrals for legal sanctions; monitor provider background screening processes taking appropriate actions when providers have disqualifying offenses; participate on the Clearinghouse Advisory Board; coordinate with Medicare related to mismatches in provider data between PECOS and the MMIS; coordinate requests for onsite reviews with the RPA Onsite Review Desk; perform change of ownership reviews, including determining if there is any pending enforcement action by MPI or MFCU, verify accuracy of ownership disclosures, and identify any money owed by the seller or the buyer; and participate in an interagency workgroup on provider license compliance.

Provider Business Module Management

Responsible for the business of provider enrollment. Staff will design, develop, and implement solutions for provider regulation compliance through close coordination with the Centers for Medicare and Medicaid Services, the Office of the Inspector General, and Medicaid Program Integrity, and other states' Medicaid programs; coordinate with internal and external partners in support of the Medicaid Enterprise System and operational processes; participate in development and implementation of system enhancements through close working relationship with the fiscal agent; represent the Agency on national meetings and work groups related to provider screening; develop operational process standards through process mapping; develop reporting mechanisms to manage Provider Enrollment Unit workloads and data anomalies; document regulatory requirements and proof of compliance; provide transparency to Provider Enrollment Unit activities; assist Medicaid Policy and Publication Units with maintenance of provider guides, training materials, and rule documents; and design, develop, and implement fiscal agent monitoring processes and reporting mechanisms in support of contract enforcement, including the use of CAPs and sanctions to enforce compliance.   

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