Additional Prior Authorization and Claims Payment Requirements for Providers Rendering Services in the Statewide Medicaid Managed Care Program

April 29, 2020

The Agency for Health Care Administration (Agency) is committed to assisting providers and ensuring Florida Medicaid recipients receive necessary care during the 2019 novel coronavirus (COVID-19) state of emergency.

As previously communicated, the Agency has required Medicaid health plans to waive prior authorization for the following services for all enrollees: hospital services (including behavioral health and long-term care hospital services), skilled nursing facility services, physician services, advanced practice registered nursing services, physician assistant services, home health services, and durable medical equipment and supplies. In addition, health plans must waive prior authorization for all services for enrollees diagnosed with COVID-19.

For all services in which prior authorization requirements are waived, each Statewide Medicaid Managed Care plan must:

  • Relax prior authorization edits in its claims system.
  • Continue to ensure compliance with national correct coding requirements.
  • Not impose penalties on providers for failing to notify the plan of the provision of services.
  • Not reduce coverage or payment of emergency department services (i.e., down coding) provided during the state of emergency based on final diagnosis on the claim.
  • Not deny, delay, or recoup payment of clean claims by implementing prepayment or post-payment review procedures for services in which prior authorization is waived, except as follows:

The health plan may:

deny payment

  • When the service was not covered by the health plan.
  • When the service was furnished by a provider prohibited by the contract from participation as a managed care plan provider as stipulated in the health plan’s contract.

delay payment and require proof of medical necessity

  • When there is compelling suspicion that the service was fraudulently provided.
  • When the service was provided in violation of Executive Order 20-721.
  • If a provider was previously placed on pre-payment review due to aberrant billing activity.
  • Related to durable medical equipment, when the item requires customization (e.g., customized wheelchairs)

Executive Order 20-72 prohibits providers from rendering any medically unnecessary, non-urgent, or non-emergent procedure or surgery which, if delayed, will not place the patient’s health at risk.

The health plan remains responsible for complying with fraud, abuse, waste, and overpayment requirements in the SMMC contract.