The following pages contain charts that provide special requirements for each type of provider that uses the Florida Medicaid Provider Enrollment Application to enroll in Medicaid. You may use these charts as a guide in completing the enrollment process for the Florida Medicaid program.
Please note: All providers must complete either an Institutional or a Non-Institutional Medicaid Provider Agreement and submit the agreement with the enrollment application. Enrollment applications that do not include the designated agreement will be returned to the provider. Providers must resubmit the enrollment application with the designated agreement before the enrollment can be processed.
All provider enrollment forms can be obtained from ACS State Healthcare’s Florida Medicaid website at http://floridamedicaid.acs-inc.com or from ACS Provider Enrollment by calling 1-800-377-8216 or from the area Medicaid office. See page 52 of this guide for the office that serves your area.
Visit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 39
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form Aging & AdultServices (AAS)
80 35 25 80
•
Group practice Sheet•
Enrollment Application•
Institutional Medicaid ProviderAgreement
•
Electronic Funds Transfer form•
Have an agreement with CMSto operate as an ASC Ambulatory
Surgical Center (ASC)
06 30 06
•
Be licensed by HQA as an ASC•
Enrollment Application•
Institutional Medicaid Provider Agreement•
Electronic Funds Transfer form Assistive Care Services (ACS) 14 30 80 A1 A2 A3 A4 A5A6
•
Copy of ALF, AFCH or RTF license•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form Audiologist 60 3035 60
•
Copy of professional License from MQA•
Enrollment Application•
Non-Institutional Medicaid Provider Agreement Billing Agent 99 30•
Background Screening (fingerprint card & $47)Provider Description Provider Type Practice Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of Birth Center licensefrom HQA
•
Copy of current facility licenseBirth Center 69 30 69
55
•
Include Medicaid ID numbers for all practitioners•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Group practice sheet•
Have current ADM contract plus Appendix A, B, or C of the Medicaid Coverage and Limitations Handbook Case Management Agency Mental Health Targeted Case Management 91 35 75•
Have individual staff providing TCM services certified by ADM or CMS (Appendix D or E of the Medicaid Coverage and Limitations Handbook or Child Welfare TCM Agency Certification form)•
Enrollment Application•
Non-Institutional Medicaid Provider Agreement•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Group practice sheet•
Have a contract with CMS•
Be certified by CMS Children’s Medical Services (CMS) 78 35 25 35 55 60 62 75•
Have individual staff providing TCM services certified by CMSVisit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 41
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH Chiropractor 28 30 31 33 35 28 66 89
•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Current contract with ADM•
Have a waiver letter from DCFapproving contract
•
Have copy of contract between provider agency and consulting physician or psychiatrist as a staff member•
Have documentation the physician or psychiatrist is independently enrolled in Medicaid•
Group practice sheet CommunityMental Health Services
05 35 05
•
Pre-certification review and approval by Medicaid Services are required prior to enrollment activation.•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Group Practice sheetCounty Health Department (CHD) 77 35 25 30 35 55 64 72
•
Approval by Medicaid Services for CHD Certified Match ProgramProvider Description Provider Type Practic e Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of professional licensefrom MQA
•
Specialty 72, 73, 88 requires Board Certification or Board Eligibility Dentist 35 30 33 35 35 66 70 71 72 73 74 88•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Current copy of all requiredlicenses (Specialty code 69, Oxygen, requires a copy of the valid oxygen Retailer license.)
•
Copy of current occupationallicense
•
$50,000 Medicaid Surety Bond Durable Medical Equipment (DME) Medical Supplies 90 30 90 65 69•
Site Visit•
Enrollment Application•
Non-Institutional Medicaid Provider Agreement•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
CMS/EIP approvalrecommendation letter
•
Early Intervention TrainingCertificate from CMS/EI Early Intervention Services Para- professional 82 30 35 24
•
Copy of professional/paraprofessional healing arts licenseVisit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 43
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
CMS/EIP approvalrecommendation letter
•
Early Intervention TrainingCertificate from CMS/EI Early Intervention Services Professional 81 30 35 24 75 80
•
Copy of professional/paraprofessional healing arts license•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form Federally Qualified Health Center (FQHC) 68 35 25 27 28 30 35 55 6272
•
Copy of Public Health Grant document•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form Free-StandingDialysis Center
89 30 16 89
•
Medicare certification letter with Medicare number•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of professional licensefrom MQA Hearing Aid
Specialist 61 30 35 60
•
Group practice sheet (if applicable)Provider Description Provider Type Practic e Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Approval by Waiver Specialistin the approving department, agency or organization co- administering the waiver type Home & Community Based Services 67 30 35 80 68 79 89 94 95 96 97 98 99 CF AZ
•
Surety bond required for DME or HHA entities that are not Medicaid enrolled.•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
HHA approval (survey by HQA)•
Copy of current license fromHQA Home Health Agency (HHA) 65 30 99 65 90 90 91 92
•
Surety bond required if have had sanctions or terminations within the past 5 years.•
Certification & TransmittalSurvey form from HQA
•
Non-Institutional MedicaidProvider Agreement
Hospice 15 30 15
89
•
Medicare certification letter•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of current clinicallaboratory facility license from HQA
•
CLIA certification•
HCFA-1513 form IndependentLaboratory 50 30 50
•
$50,000 Medicaid surety bond (1st yr of enrollment)Visit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 45
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of current professionallicense from MQA Licensed
Midwife 34 30 35 30 55
•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Be licensed by DCFMedical Foster Care Personal Care
23 30 24
•
Have a copy of completion of a Medical Foster Care training program conducted by CMS•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH
•
Group practice sheet (if applicable) Nurse Practitioner (ARNP) 30 30 35 30 55 64 66 72 75 75 76 77 78 80 81 82 83 84 85 86 87•
Collaborative agreement (form in application or on a separate collaboration form signed by a physician)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH
Optician 63 30
35 62
•
Group practice sheet (if applicable)Provider Description Provider Type Practic e Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH Optometrist 62 30
35 62 66 25
•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer formPharmacy 20 20 21 22 23 24 25 89 20
•
Copy of DEA License, Pharmacy permit & Pharmacist’s license•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH
•
Pediatric Surgery and Urology require copy of BoardCertification
•
Group practice sheet (if applicable)•
If Group – need Certificate of Ownership form Physician (MD & DO) 25 / 26 30 31 32 33 35 25 55 60 62 64 66 72 82 89 01 Thru 67•
Physician Groups more than 50% owned by non-physicians require:$50,000 Medicaid surety bond
Visit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 47
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH
•
Collaborative agreement (form in application or on a separate collaboration form signed by a physician) Physician Assistant 29 30 35 30 55 64 66 72•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH Podiatrist 27 30 31 33 35 27 66 89
•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of Medicare certificationfrom HQA Portable X-ray 51 30 51
•
HCFA-1513•
Enrollment Application•
Non-Institutional Medicaid Provider Agreement•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of current PPEC license Prescribed Medical Rehabilitative Services (PPEC) 24 99 24•
Copy of current occupational licenseProvider Description Provider Type Practic e Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Copy of professional licensefrom DOH Registered Nurse (RN) Registered Nurse First Assistant (RNFA) 31 30 35 30 55 64 75
•
Group practice sheet (ifapplicable – required with CHD or CMS)
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form Rural Health Clinic (RHC) 66 35 25 27 28 30 55 62 64 66 72 89•
Proof of Medicare certification•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Electronic Funds Transfer form•
Medicaid Services approval School District 08 30 35 05 25 30 35 40 55 60 62 75 80 83•
Enrollment Application•
Non-Institutional Medicaid Provider Agreement•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Be certified by ADM or CMS•
Be member of a CaseManagement Agency (PT-91) or CMS office or clinic (PT-78)
•
If with ADM – need appropriateappendix form Social Worker
Case Manager
32 30 75
•
Copy of current occupational licenseVisit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 49
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Be certified by AHCA, ADM andDJJ
•
Have current contract with ADM SpecializedMental Health Practitioner
07 30
35 05 66 67
•
Completed certification forms Appendix C (Comprehensive Behavioral Health Assessment) or Appendix D (Specialized Therapeutic Foster Care) of the Medicaid Provider Coverage and Limitations Handbook•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Copy of current licenseTherapist 83 30
35 83 90 91
92 93
•
Group practice sheet (if applicable)•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Copy of EMS permit from DOH•
Local & State licensure (asapplicable) Transportation
Air Ambulance
42 30 40
Provider Description Provider Type Practice Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Copy of EMS permit from DOH•
Local & State licensure (asapplicable)
•
Copy of Medicare licensure & certificationTransportation
Ambulance 40 30 40
•
Area Medicaid office approval•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Local & State licensure (as applicable)•
Proofs of insurance•
Contract with CTC•
Surety bond for first year of enrollment, unless enrolled with zero rates Transportation Multi Load Private Transportation 47 30 40•
Area Medicaid office approval•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Local & State licensure (as applicable)•
Proofs of insurance•
Contract with CTC Transportation Non Emergency Medical Vehicles 41 30 40•
Visit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 51
Provider
Description Provider Type Practice Type of Service Category Specialty Requirements for Medicaid Provider Applicants:
•
Surety bond for first year ofenrollment, unless enrolled with zero rates
Transportation Non
Emergency Medical
Vehicles (cont.)
•
Area Medicaid office approval•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Local & State licensure (as applicable)•
Proofs of insurance•
Contract with CTC Transportation Non Profit Transportation Carrier 46 30 40•
Area Medicaid office approval•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47) – not required with Medical Foster Care license from DOH
•
Electronic Funds Transfer form•
Copy of vehicle registration•
Proofs of insurance•
Valid Florida driver’s license TransportationPrivate 45 30 40
•
Area Medicaid office approval•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Local & State licensure (as applicable)•
Contract with CTC TransportationPublic 44 30 40
Provider Description Provider Type Practice Type Category of Service Specialty
Requirements for Medicaid Provider Applicants:
•
Enrollment Application•
Non-Institutional MedicaidProvider Agreement
•
Background Screening(fingerprint card & $47)
•
Electronic Funds Transfer form•
Rate sheet from area Medicaidoffice
•
Local & State licensure (as applicable)•
Proofs of insurance•
Contract with CTC•
Surety bond for first year of enrollment, unless enrolled with zero ratesTransportation
Taxi 43 30 40
Visit the fiscal agent web site for electronic versions of all enrollment forms: http://floridamedicaid.acs-inc.com
July 2005 Page 53