Provider Guide: AHCA Rules For Medicaid Enrollment, Billing
Date: 08/31/24
Sunshine Health reminds providers that AHCA has set important enrollment and billing requirements that they must follow as Medicaid providers.
Here’s a guide to help providers understand those rules and how to resolve any issues you may encounter:
Provider Data: Check These Reports
AHCA shares provider data via three reports: The Provider Master List (PML), the Pending Provider List (PPL) and the Taxonomy Master List (TML), a report of provider specialties.
- Provider Master List (PML): Provided to Medicaid health plans so they can verify if providers in their networks are enrolled in Medicaid. It can also be used to reconcile demographic data between the plans' databases and Medicaid.
- Pending Provider List (PPL): Provided to Medicaid health plans so they can verify if providers that do not currently have Medicaid Provider IDs have applied to Medicaid.
- Taxonomy Master List (TML): Contains the taxonomy codes for every provider specialty accepted by Florida Medicaid.
Provider Enrollment: Medicaid IDs
- Medicaid IDs should be indicated as “active” on AHCA’s PML, compliant and enrolled as “Enrollment” or “Limited Enrollment”
- Providers should refer to the Provider Enrollment Policy (PDF) to confirm their Medicaid enrollment requirements
- There are limited exceptions for providers eligible to enroll with “Registered” status on the PML, including:
- Provider Type 07 (Specialized Therapeutic Services)
- Provider Type 16 (Out of State Residential and Freestanding Psychiatric Facility)
- Provider Type 97 (Managed Care Treating Provider)
- To apply directly to Medicaid, providers can submit either a Limited Enrollment or a Full Enrollment application via the Provider Enrollment Wizard
- NOTE: Full Enrollment is required if the provider is to bill Medicaid as fee-for-service.
Provider Enrollment: NPI Numbers
Providers must have the following National Provider Identification (NPI) information associated with their Medicaid account when enrolling with Florida Medicaid:
- Individual Providers (NPI Type 1) — Rendering
- Organizational/Group Providers and Medicaid Health Plans (NPI Type 2) — Billing
Denial Code | Description | Next Steps Towards Resolution |
|---|---|---|
EXGp: Claim submitted with inactive group Medicaid ID | Practitioner is affiliated with a provider group or facility that is not properly or completely enrolled in AHCA’s PML | Resolution 1: For those who do not want to be a solo practitioner and/or want to add additional practitioners to their agreement:
Resolution 2: For solo practitioners who want to add other practitioners to their agreement.
|
EXin: Contact AHCA to complete enrollment of your Medicaid ID | Medicaid ID enrollment type is invalid for the AHCA provider type listed on AHCA’s PML | Review AHCA’s PML to confirm that each Type 1 (Practitioner) and Type 2 (Billing) NPI for your organization is identified and active on the PML with Fully Enrolled or Limited Enrolled status. Providers have a federal requirement to complete their Medicaid enrollment. Please complete the online profile/application. The provider types below can remain in “Register” status on the PML:
Providers should refer to the Provider Enrollment Policy (PDF) to confirm Medicaid enrollment requirements |
EXMA: Medicaid ID is missing or not on file | Provider or practitioner’s Medicaid ID is not valid on AHCA’s PML because of one of following reasons:
| Review AHCA's PML to confirm that each Type 1 (Practitioner) and Type 2 (Billing) NPI for your organization is identified and active on the PML. Complete or renew enrollment for each NPI within your organization directly with AHCA. Note: Claims should be corrected and resubmitted. |
EXMd: Need to link an MD or DO to receive payment | Practitioner is affiliated with a behavioral health group (provider type 05 or 07); and that group does not meet the AHCA requirement to employ an MD or DO | Providers should refer to the Provider Enrollment Policy (PDF) to confirm their Medicaid enrollment requirements |
EXNPI: Depends on the reason | Different reasons can apply here: NPI not found; NPI date on PML has passed and is no longer valid; effective date is missing; CMS has deactivated the NPI number |
|
EX33: Resubmit claim with billing NPI in Box 33a | Practitioner is part of/affiliated with a group practice that has an NPI Type 2 (organization identifier); however, when submitting claims, practitioner is using their individual NPI Type 1 incorrectly in Box 33a of the claim form or are omitting the Type 2 NPI in Box 33a on the claim form | Claims can be resubmitted by using the appropriate Type 2 NPI in Box 33a For solo practitioners, this denial should not be impactful; however, if a denial is received and the provider believes it is in error, they can submit a request to update our records for a Group or Solo practice via these avenues:
|
Exch: Claim billed with invalid Tax ID or NPI due to Change of Ownership (CHOW) | Provider’s business has undergone a change of ownership. This denial is applied to ensure that payments are correctly directed to the new owner and/or new business entity | Review information under current CHOW to ensure information on claim is billed according to the new entity If you need to submit a CHOW, complete this online form. This will be directed to the Contracting Department via email at: SunshineContracting@sunshinehealth.com |
EX2B: Expired or invalid credentials | Practitioner or providers license has expired | The practitioner or providers medical license is not valid due to one of the reasons below:
All those who participate with Medicaid or Florida Children's Health Insurance Program (CHIP) are required to maintain an active medical license Check your license via this web tool: Florida Department of Health License Verification
|
EX4G: Medicaid sanctioned/termed/excluded provider | AHCA has terminated the providers Medicaid ID | This termination occurred because:
Best practice is to contact AHCA.
|
EXSn: No payment per State withhold/suspension notice | Health plan has been instructed to suspend payments due to an outstanding financial obligation to a third party | This typically remains in effect until the debt has been settled or other arrangements are made Best practice is to contact AHCA. |
Provider Resources
Providers with questions about how to update the PML should contact AHCA and/or visit the Florida Medicaid Web Portal.
Providers with questions about NPIs should check Gainwell’s NPI Quick Reference Guide (PDF).
The following resources can help providers submit claims:
- Sunshine Health Provider Billing Manual for Medicaid (PDF)
- Centers for Medicare & Medicaid Services: Completing and Processing
- Form CMS-1500 Data Set (PDF)
- National Uniform Claim Committee (NUCC): 1500 Claim Form Reference Instruction Manual
- American Medical Association (AMA) Medicare & Medicaid Resources: Offers resources and training on proper Medicaid billing practices
Questions?
If you have any questions, please call Sunshine Health Provider Services at 1-844-477-8313 or visit the Secure Provider Portal. Our Provider Engagement staff are also here to help answer questions. Visit the Find Your Provider Engagement Account Manager tool to confirm the individual supporting your specialty and region. We encourage you stay up to date on Sunshine Health provider notices by reviewing and bookmarking Provider News.
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