Florida

To calculate a Florida Medicaid claim at 100% of the state regulation rates, use the default settings. The required fields are identified on the image below. Optional fields are either applied or not applied based on the specific contract language.

Note: Refer to the contract to determine the options to select and the values to enter.

The following settings are required or recommended for Florida Medicaid managed care contracts:

  • Override Provider Number – Type the preferred provider number (required).
  • State Code – Defaults to FL (this value cannot be changed).
  • Percent of Reimbursement – This should be set to 100% unless specified otherwise (required).
  • Disable inpatient cap – Provides the option to ignore the day cap Medicaid places on inpatient claims (optional).

    • Note: Typically, this option is only selected for managed care contracts that reimburse based on traditional Medicaid, but without the inpatient cap.

  • Percent of Fee Schedules – Provides the option to calculate reimbursement as a set percentage of the Medicaid fee schedule amount (optional). Typically, this option is selected for managed care contracts that reimburse based on traditional Medicaid.

    • Note: The Percent of Reimbursement overrides the Percent of Fee Schedules. For example, if the Percent of Reimbursement is set at 105% the fee schedule rates would reimburse at 105%. This option is to be used only when labs or newborn hearing services are the only services that pay over or less than 100% of Medicaid reimbursement.

  • Use APR DRG – Provides the option to calculate reimbursement using the All Patient Refined Diagnosis Related Group (APR-DRG) payment methodology.

    • Note: This required ONLY if you want to reimburse using the APR DRG pricing logic.

The Allow Multiple Rev. Code 636 Lines check box on the FL Medicaid Term Reimbursement Editor provides the option to allow multiple revenue code 0636 line items to reimburse per date of service.

  • Click this check box to allow multiple revenue code 0636 line items to reimburse per date of service.

    • Note: This box is checked by default.

  • Clear this check box to disallow multiple revenue code 0636 line items to reimburse per date of service.

Interactions between the Allow Multiple Rev. Code 636 Lines check box and the Cap line items at lesser of billed charges or Medicaid reimbursement check box are specified in the following four scenarios:

  • All revenue code 636 lines are reimbursed at the lesser of billed charge for one unit or line item rate. This is the current behavior, no changes
  • All revenue code 636 lines are reimbursed at the line item rate. This is the current behavior, no changes.
  • Only one revenue code 636 line is reimbursed per service day at the lesser of billed charge for one unit or line item rate. The chosen line item is the one with the maximum billed charge among all revenue code 636 line items of the same day.
  • Only one revenue code 636 line is reimbursed per service day at the line item rate. It does not matter which line is reimbursed because the line item rate is the same. However, to be consistent with scenario three, the line item with the maximum billed charge among all revenue code 636 line items of the same day will be reimbursed.

To cap at billed charges, select both the Cap line items at lesser of billed chargers or Medicaid reimbursement and Use EAPG check boxes. This allows you to have line items reimburse at billed charges if the expected is higher than the billed amount.

The following table describes the fields on the FL tab of the Medicaid - Facility reimbursement tool.

Field

Description

Override Provider Number

Preferred provider number. Up to ten alphanumeric digits.

Override Service Date

Preferred service date. Use MM/DD/YYYY format. Overrides the service date on the claim with the date you enter. You may use the anchor date instead of this option.

State Code

This field defaults to FL, and it cannot be changed.

Do not consume charges

Provides the option not to consume charges. This is used for contract carve outs.

Do not consume units

Provides the option not to consume units. This is used for contract carve outs.

Percent Reimbursement

Three digit percentage amount.

Cap line items at lesser of billed charges or Medicaid reimbursement

Provides the option limit the calculated reimbursement at the line item level for outpatient claims to the lesser of the billed charges or the Medicaid reimbursement. Selecting this option ensures the calculated reimbursement never exceeds billed charges.

OP

Use EAPG

Select to enable EAPG pricing.

Set Revenue Code Overrides

This section allows you to enter percent overrides for specific revenue codes. To access the Set Revenue Code Overrides section, click Set Rev Code Overrides.

  • To enter an override, type the revenue code in the Revenue Code field and type the override percentage in the % field. For example, typing 250 in the Revenue Code field and 50 in the % field causes all revenue 250 codes to reimburse at 50% of charges.
  • To enter an override for a range of revenue codes, type the revenue code range in the Revenue Code field and type the override percentage in the % field. For example, typing 250-259 in the Revenue Code field and 50 in the % field causes revenue codes 250 through 259 to reimburse at 50% of charges.

Note: This allows pass-throughs and carve outs in managed care contracts to use this reimbursement tool.

Percent of Fee Schedules

Provides the option to calculate reimbursement as a set percentage of the Medicaid fee schedule amount. For example, the user can specify reimbursement as 105% of the Medicaid rate. Typically, this option is selected for managed care contracts that reimburse based on traditional Medicaid.

Disable outpatient cap

Provides the option to ignore the monetary cap Florida Medicaid places on outpatient claims. Typically, this option is only selected for managed care contracts that reimburse based on traditional Florida Medicaid, but without the outpatient cap.

Allow Multiple Rev. Code 636 Lines

Provides the option to allow multiple revenue code 636 line items to reimburse per date of service.

  • Click this check box to allow multiple revenue code 636 line items to reimburse per date of service.
  • Clear this check box to disallow multiple revenue code 636 line items to reimburse per date of service.

Note: This box is checked by default.

NDC Required for Rev Code 636

Provides the option to require a valid NDC code to price revenue code 636 line items on OP claims. This option works in conjunction with Allow Multiple Rev. Code 636 Lines:

  • If Allow Multiple Rev. Code 636 Lines is selected, multiple Rev Code 636 line items with valid NDC numbers will be priced at the OP line item rate.
  • If Allow Multiple Rev. Code 636 Lines is not selected, only one Rev Code 636 line item with a valid NDC number is paid – capped at the line item rate.

Ignore Age Restriction

Provides the option to ignore the Newborn Hearing Age restriction for claims with Rev Code 0471 and CPT Codes 92585-92588 if the patient is older than 12 months .

Price to zero on error

Enable (check) this option to include accounts that fail to price due to an error display with an expected reimbursement amount of zero ($0). When this check box is disabled (not checked), accounts price to 100% of billed charges.

IP

Use APR-DRG

Provides the option to calculate reimbursement using the All Patient Refined Diagnosis Related Group (APR-DRG) payment methodology.

Note: Implemented by Florida Medicaid beginning 07/01/ 2013.

Disable inpatient cap

Provides the option to ignore the day cap Medicaid places on inpatient claims. Typically, this option is only selected for managed care contracts that reimburse based on traditional Medicaid, but without the inpatient cap.