Fl Provider Application – Fill Out and Use This PDF

Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

Table of Contents

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

1 Purpose

The Agency for Health Care Administration (Agency) and its fiscal agent, Gainwell Technologies (Gainwell), have created this comprehensive reference guide to assist applicants with completing the enrollment process using the Florida Medicaid online enrollment wizard. This guide references and ties together provider enrollment-related information that is publicly available on the Florida Medicaid Web Portal, and provides guidance for completing the process for submission, uploading documentation, and verifying the status of a submitted application. All public Web Portal resources can be accessed via http://www.mymedicaid-florida.com. Agency resources can be found on the Agency page at http://ahca.myflorida.com.

2.1General Information

In order to receive Medicaid reimbursement, a provider must be enrolled in Medicaid and meet all provider requirements at the time the service is rendered. Every entity that provides Medicaid services to recipients and all third-party software vendors offering services of any kind to providers must enroll as a Medicaid provider.

2.2Enrollment Qualifications

Providers must meet all provider requirements and qualifications. Practices must be fully operational before they can be enrolled as Medicaid providers. General enrollment requirements are covered in the Medicaid Provider General Handbook. Program specific qualifications for each provider type are listed in the Coverage and Limitations Handbooks. All handbooks are available at https://ahca.myflorida.com/.

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

2.3Accuracy of Information

All enrollment statements or documents submitted to the Agency for Health Care Administration (Agency) or the Medicaid fiscal agent must be true and accurate. Filing of false information is sufficient cause for denial of an enrollment application or termination from Medicaid participation.

2.4Notice Regarding Use of Social Security Number

As a part of your application for enrollment as a Florida Medicaid provider, all individuals listed as Owner(s) and Operator(s) are required to provide their social security number (SSN) to the Agency pursuant to 26 U.S.C. 6109. Disclosure of your social security number is mandatory. Failure to provide your social security number will be a basis to refuse to enroll you as a Medicaid provider.

Your social security number will be used to secure the proper identification of persons for whom the Agency is responsible for making a return, statement, or other document in accordance with the Internal Revenue Code, and to assist in the administration of the Florida Medicaid program.

2.5Supporting Documentation Requirements

The application process cannot be completed until all required documents as stipulated in the applicable Handbook sections, including an accurately completed Florida Medicaid provider agreement and background screening, are received.

Applicants must include the Application Tracking Number (ATN) provided by the Online Enrollment Wizard when uploading supporting documents.

Please visit the Enrollment Forms page via http://www.mymedicaid-florida.com to obtain the forms needed for initial enrollment. Applicants are encouraged to use the Interactive Enrollment Checklist tool to verify supporting documentation requirements prior to completing their online application.

2.6Enrollment Process

Most provider enrollment applications will go through the following process:

1.Applicant submits an Enrollment Application via the Florida Medicaid Web Portal Online Enrollment Wizard.

2.The Enrollment Application is evaluated based on the enrollment rules. The Agency completes the credential verification process and site visit, when applicable.

3.The Enrollment Application is finalized. Provider receives a letter containing the final status, whether approved or denied.

4.Once the Enrollment status is Active, the provider receives a Welcome Letter, and Florida Medicaid ID. Full and limited enrolled providers will also receive a PIN Letter, that will be used to create a secure web portal account.

3 Before You Enroll

Before initiating the enrollment process, please follow the instructions listed below:

1.Review the Provider General Handbook, Chapter 2, for general enrollment requirements. The handbook is located on the Agency’s website at http://ahca.myflorida.com.

2.Determine which Enrollment Type will be used.

3.Determine which Provider Type and Specialty will be used. View the Provider Type and Specialty to learn which qualifies for fully enrolled, limited enrolled, or order or referring enrollment.

4.Refer to the Interactive Enrollment Checklist to identify enrollment application requirements based on enrollment type, application type, provider type, and specialty, prior to starting the application process. To access the Interactive Enrollment Checklist, visit mymedicaid- florida.com. From the homepage, hover over the Provider Services tab, and click Enrollment. Once at the Provider Enrollment page, look under the New Medicaid Providers section, and click Interactive Enrollment Checklist.

5.Before the application can be submitted, all supporting documentation must be uploaded.

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

4 Submitting a Provider Enrollment Application

The Florida Medicaid Provider Enrollment Application gathers information related to the applicant’s eligibility to enroll in Florida Medicaid. Providers use this page to complete an enrollment application to become a participating provider in the Florida Medicaid program.

The following provides guidance for accurately reporting the elements of the application. By logging into the secure Web Portal at http://www.mymedicaid-florida.com, providers can complete their enrollment application by navigating to Provider Services tab and clicking on the Enrollment.

The online enrollment application cannot be used if applying for Out of State Enrollment or Additional Location Codes.

4.1Navigation

4.2Welcome Statement

Upon launching the Florida Medicaid Enrollment Application Wizard, applicants will be greeted with a Welcome Statement panel, and will have the option to create a new application or access on that was previously started.

4.3Enrollment Type

The Enrollment Type Determination panel will ask the applicant to choose the option that most accurately describes the reason they are applying to be a Medicaid provider. The selection made on this panel will determine all of the steps that will follow in the application.

Provider must enroll as one of the following:

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

Fully Enrolled allows providers to:

•Bill for services and receive payment directly from Medicaid.

•Participate in both the network of a Medicaid health plan as well as to bill for services and receive payment directly from Medicaid.

Limited Enrolled allows providers to:

•Participate in the network of a Medicaid health plan.

Ordering or Referring will allow providers to:

•Participate solely as a physician, or other professional practitioner, as a referring, ordering, certifying, or prescribing provider of items or services for Medicaid recipients.

4.4Enrollment Type Confirmation

After selecting the desired enrollment type determination response, providers will reach the Enrollment Type Confirmation panel that will confirm the selection made on the previous screen.

If a choice was made incorrectly, providers can click previous or if correct, click continue.

4.5Application Tips

Providers are encouraged to obtain all necessary documents or information, before proceeding with the application. The Application Tips panel lists details that may be necessary to complete application processing.

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

4.6Request Type

The information presented in the Request Type panel results may vary. The information displayed is contingent on the enrollment type selected in the previous panel. Applicants will only be presented with provider type and specialty selections that are available for the enrollment type selected, as well as taxonomies that align to the specialties chosen. Applicants may view the Provider Type and Specialty crosswalk to learn which qualifies for fully enrolled, limited enrolled, or ordering or referring enrollment.

Applicants must also select an Application Type within the panel.

A Sole Proprietor is an individual who plans to bill Medicaid directly. This option should be selected if you are individual that plans to submit claims to Medicaid and receive payments directly.

A Sole Proprietor Enrolling as a Member of a Group is an individual who plans to bill solely through a group membership and will not submit claims or receive payment directly from Medicaid.

Group should be selected if there is more than one member.

A Facility or Other Business Entity should be selected if the applicant is an entity that is formed and administered in accordance with commercial laws in order to engage in business activities

4.6.1 Change of Ownership Application

If the applicant is seeking to submit a CHOW application, they can visit the CHOW page on the public Web Portal for more information.

If the application is based on a change of ownership (CHOW) providers applying for full enrollment should select Yes to the CHOW question and enter the previous owner’s information such as the Name, Provider Number, Federal Tax ID, and Date of CHOW into the required fields. They must also upload the supporting documentation for the CHOW.

Note: Once an application is submitted, the CHOW response cannot be changed and a new application will be required if updates are needed.

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Florida Medicaid Provider Enrollment Application Guide – Version 2.0 – April 2021

4.7Before You Continue

Providers should obtain the information below before proceeding with the remainder of the application.

4.8Identifying Information

4.8.1 Provider Name

This is the legal name by which you are known to the Internal Revenue Service. Enter the name of the entity or the last name, first name, and middle initial of an individual. The name must also match the name listed on the provider’s license.

4.8.2 Doing Business As (D/B/A)

This is for individual or entity applicants doing business under a trade or company name. Individual providers doing business under his/her own name should leave this section blank.

4.8.3 Tax Identification Number (TIN)

•Social Security Number (SSN) - Individual providers who are not personally incorporated will enter their SSN and supply a copy of their Social Security card.

Note: Individual providers may not use their employer’s Tax ID on their individual provider file.

•Federal Employer Identification Number (FEIN) - Enter your FEIN if you are an entity or are individually incorporated. Attach a legible copy of proof of Tax ID such as an IRS Form SS-4, 1072, 147c, or W-9 to verify ownership of the Tax ID.

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