Florida Medicaid Managed Care Treating Provider Registration by sot11826


									Florida Medicaid Managed Care Treating Provider Registration
In order for Managed Care Organization (MCO) encounter data to be accepted by FMMIS, providers must be known to the
system through enrollment in the fee-for-service (FFS) program or registration as a Health Plan provider. Each Health Plan
provider is required to have a unique Medicaid provider number (Medicaid ID) and a National Provider Identifier (NPI). MCOs
are required to make a good-faith effort to ensure a provider is recognized by Florida Medicaid. Good-faith efforts include, but
are not limited to, the following:

       The Health Plan verifies that the provider is or will be enrolled and credentialed in the state’s Medicaid FFS program.

       The provider submits to the Health Plan a Managed Care Treating Provider registration form that indicates the provider
       is a participating provider in one or more Medicaid health plans but not enrolled or credentialed in the Medicaid FFS
       program. The interactive form is included with this instruction packet, and is available for download on the Current
       Information section of the MEDS Website.

It is the MCO’s responsibility to ensure that the providers it utilizes are registered with the Florida Medicaid program. It is also
the MCO’s responsibility to send the signed registration forms to Provider Enrollment. Registration forms sent by providers
will not be processed.

This packet provides guidance for MCOs in the registration of managed care treating providers. If you have questions, need
additional information, or have a suggestion, please contact the MEDS Team via email at MEDSteam@ahca.myflorida.com.

Included in this packet:
      Registering Providers…………………………………………………….……………………………………………………………………………...2

      Provider Type Codes.……..……………………………………………………………………………………………..…………………….………..5

      Specialty Codes….…………..…………………………………………………………………………………………………………………………..6

Registering Providers

The two-page Managed Care Treating Provider registration form is divided into six numbered sections. The first five sections
(up to and including the applicant attestation) convey information about the provider. Section six conveys information about the
MCO. The form must be completed and remitted to Provider Enrollment by the MCO; forms sent directly from providers to the
fiscal agent will not be processed. The MCO information and attestation must be signed by an appropriate officer or delegated
authority of the MCO (CEO, CFO, CMO, etc.).

                PAGE 1                                                          PAGE 2

                                           Sections 1-5 and the
                                                                                                            Provider attestation.
                                           Applicant Attestation
                                           relate to the provider.

                                           Section 6 and the MCO
                                           Attestation must be                                              This attestation must be
                                           completed by the MCO.                                            signed by the MCO.

We recommend MCOs complete Section 6 “MCO Information” in the online form, save the file with a new name, and then send
the file electronically to the provider being registered. The provider can then complete Sections 1-5 of the electronic version
with his/her information, print and sign the registration form, and send it back to the MCO. At this point the MCO can sign the
“MCO Attestation” and send the form to Provider Enrollment.

Section 1: Provider Name
The applicant (provider) should enter their name, and, if applicable, a Doing Business As (DBA) designation.

Section 2: Tax Information
The applicant should check the appropriate box to indicate a Social Security Number or Federal Employer Identification
Number and include the appropriate nine-digit number.

Section 3: Address Information
The applicant must enter an address that is a physical location (no Post Office Boxes or mail service centers).

Section 4: Service Type Information
The applicant should enter their appropriate provider type and specialty codes, which are included with this instruction booklet
(pp. 5-7).

Section 5: Provider Identifier Information
The applicant should enter the appropriate identifying information, which can include NPI, taxonomy, professional or facility
license, pharmacy permit, and/or their CLIA Certificate information. Updated documentation and the complete Health Care
Provider Taxonomy are available from the National Uniform Claim Committee.

Upon completion of the first five sections and the Applicant Attestation, the provider should return the form to the

  Important: If the provider refuses to complete the registration form, the MCO can submit the Managed Care Treating
  Provider registration form and request that the Agency register the provider with the Medicaid program. The MCO
  Attestation includes language relating to a provider’s refusal to sign the form. This process does not obligate the provider
  to participate with other health plans or the state Medicaid FFS program.

Section 6: MCO Information
The MCO must complete this section completely and accurately. To avoid delays in provider registration, the MCO should
ensure the accuracy and completeness of the provider’s information. The MCO Information section as well as the MCO
Attestation, if applicable, must be completed in full and signed by an officer of the company (CEO, CFO, CMO, etc.) or by a
delegated authority. Provider Enrollment only accepts forms containing original, “wet” signatures for Providers and
MCOs. Copies of the original registration form will not be processed.

The completed registration form should be sent to the fiscal agent’s Provider Enrollment Office (please note that the addresses
for regular mail and overnight/express delivery are different).

The MEDS Team would like to remind MCOs to retain a copy of the completed registration form for their records. As an added
layer of tracking, the MEDS Team strongly recommends that the MCO create (scan) a backup image of the completed and
signed registration form and send the scanned version to the MEDS Team (MEDSTeam@ahca.myflorida.com).

Provider Type Codes
 80   Aging & Adult Services                        44   Government/Municipal Transport                      66   Rural Health Clinic

 42   Air Ambulance                                 61   Hearing Aid Specialist                              08   School District

 40   Ambulance                                     41   Non-Emergency Transport                             10   Skilled Nursing Facility

 06   Ambulatory Surgery Center                     46   Non-Profit Transportation                           09   Skilled Nursing Unit Hospital Based

 33   Approval Agency                               86   Non-Provider Mail List Only                         70   HMO

 14   Assistive Care Services                       30   Nurse Practitioner (ARNP)                           67   Home & Community-Based Services Waiver

 60   Audiologist                                   63   Optician                                            65   Home Health Agency

 99   Billing Agent                                 62   Optometrist                                         15   Hospice

 69   Birth Center                                  82   Paraprofessional Early Intervention Services        50   Independent Laboratory

 79   Bureau of Blind Services                      20   Pharmacy                                            98   Leinholder

 91   Case Management Agency                        26   Physician (D.O.)                                    34   Licensed Midwife

 78   Children’s Medical Services                   25   Physician (M.D.)                                    23   Medical Foster Care/ Personal Care Provider

 28   Chiropractor                                  29   Physician Assistant                                 32   Social Worker/Case Manager

 05   Community Mental Health Services              27   Podiatrist                                          07   Specialized Mental Health Practitioner

 77   County Health Department                      51   Portable X-ray Company                              11   State ICF/DD Facility

 35   Dentist                                       72   Prepaid Mental Health Services                      04   State Mental Hospital

 76   Developmental Disability Agency               24   Prescribed Medical Rehab Services (PPEC)            13   Swing Bed Facility

 89   Dialysis Center                               12   Private ICF/DD Facility                             43   Taxicab Company

 90   Durable Medical Equipment/ Medical Supplies   45   Private Transportation                              83   Therapist (PT, OT, ST, RT)

 68   Federally Qualified Health Center             81   Professional Early Intervention Services            75   Vocational Rehabilitation Agency

 01   General Hospital                              31   Registered Nurse/Registered Nurse First Assistant   47   Multi-Load Private Transport

Specialty Codes


 01 Adolescent Medicine    18 Internal Medicine       37   Pediatrics, Cardiology            54   Surgery, Colon/Rectal

 02 Allergy                19 Neonatal/Perinatal      PC Pediatrics, Critical Care           55   Surgery, General

 03 Anesthesiology         20 Neoplastic Diseases     PE Pediatrics, Emergency Care          56   Surgery, Hand

 04 Cardiovascular Medicine 21 Nephrology             38   Pediatrics, Oncology/Hematology   57   Surgery, Neurological

 05 Dermatology            22 Neurology               39   Pediatrics, Nephrology            58   Surgery, Orthopedic

 06 Diabetes               23 Neurology/Children      41   Physical Medicine & Rehab         59   Surgery, Pediatric

 07 Emergency Medicine     24 Neuropathology          42   Psychiatry                        60   Surgery, Plastic

 08 Endocrinology          26 Obstetrics              43   Psychiatry, Child                 61   Surgery, Thoracic

 09 Family Practice        27 OB-GYN                  44   Psychoanalysis                    62   Surgery, Traumatic

 10 Gastroenterology       28 Occupational Medicine   45   Public Health                     63   Surgery, Urological

 11 General Practice*      29 Oncology                46   Pulmonary Diseases                65   Maternal/Fetal

GE Genetics                30 Ophthalmology           47   Radiology                         66   Comprehensive Behavioral Health Assessment

 12 Preventive Medicine    31 Otolaryngology          48   Radiology, Diagnostic             67   Specialized Therapeutic Foster Care

 13 Geriatrics             32 Pathology               49   Radiology, Pediatric

 14 Gynecology             33 Pathology, Clinical     50   Radiology, Therapeutic

 15 Hematology             34 Pathology, Forensic     51   Rheumatology

 16 Immunology             35 Pediatrics              52   Surgery, Abdominal

 17 Infectious Diseases    36 Pediatrics, Allergy     53   Surgery, Cardiovascular

Specialty Codes - Continued

 ARNPs                                               DENTISTS                              WAIVERS

 75 Adult Primary Care                               70 Adult Dentures Only                CF Adult Cystic Fibrosis

 76 Clinical Nurse Specialist Psych. Mental Health   71 General Dentistry                  95 Aged/Disabled Adults
 77 College Health Nurse                             72 Oral Surgery (Dentist)
                                                                                           AZ Alzheimer’s
 78 Diabetic Nurse Practitioner                      73 Periodontist
                                                                                           89 Assisted Living for the Elderly
 80 Family Nurse                                     74 Other Dentist
                                                                                           97 Channeling
 81 Family Planning                                  88 Orthodontist
                                                                                           98 Community Supported Living Arrangement
 82 Geriatric
                                                                                           68 Consumer Directed Care
 83 Maternal/Child Health Family Planning
                                                     DURABLE MEDICAL EQUIPMENT PROVIDERS
 84 Certified Registered Nurse Anesthetist                                                 96 Developmental Disability
                                                     69 Medical Oxygen Retailer
 85 Certified Registered Nurse Midwife                                                     94 Model

 86 OB/GYN Nurse                                                                           99 Project AIDS Care

 87 Pediatric Nurse                                  THERAPISTS                            79 Traumatic Brain Injury and Spinal Cord Injury

                                                     90 Occupational Therapist
                                                     91 Physical Therapist
  A1   Licensed Assisted Living Facility
       Licensed ALF with Extended Congregate         92 Speech Therapist
       Care (ECC) Specialty License
                                                     93 Respiratory Therapist
       Licensed ALF with Limited Nursing Service
       (LNS) Specialty License
       Licensed ALF with Limited Mental Health
       (LMH) Specialty License                        THERAPUTIC SERVICES
  A5   Licensed Adult Family Care Home                66   Comprehensive Assessment
       Licensed Residential Treatment Facility
  A6                                                  67   Therapeutic Foster Care
       (RTF’s) with less than 16 beds


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