Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59G - Medicaid › Chapter 59G-1 - GENERAL MEDICAID › Section 59G-1.060 - Provider Enrollment Policy

Current through Reg. 50, No. 138; July 16, 2024
(1) This
				rule applies to all individuals, groups, and entities that are seeking to
				enroll, renew, or maintain enrollment as an authorized provider for the Florida
				Medicaid program.
(2) All providers
				must be in compliance with the provisions of the Florida Medicaid Provider
				Enrollment Policy, January 2022, incorporated by reference. The policy is
				available on the Agency for Health Care Administration's Web site at
http://ahca.myflorida.com/Medicaid/review/index.shtml
,
				and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-13974
.
(3) The following forms are incorporated by
				reference and available on the Florida Medicaid Web portal at
				http://portal.flmmis.com/flpublic, and as follows:
(a) Case Manager Certification, AHCA Form
				5000-3537, May 2014,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11332
.
(b) Case Manager Supervisor Certification
				Targeted Case Management for Children at Risk of Abuse and Neglect, AHCA Form
				5000-3536, May 2014,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11333
.
(c) Comprehensive Behavioral Health
				Assessment Agency and Practitioner Self-Certification, AHCA Form 5000-3512, May
				2014,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11334
.
(d) Contractor Certification for Children's
				Services Council, AHCA Form 5000-3535, May 2014,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11335
.
(e) County Health Department Agreement
				Provider Credentialing of Behavioral Health Providers and Social Workers, AHCA
				Form 5000-1066, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11336
.
(f) Electronic Data Interchange Agreement,
				AHCA Form 5000-1062, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11350
.
(g) Florida Medicaid Provider Enrollment
				Application Out-of-State Fee for Service, AHCA Form 5000-1260, (JAN 2021),
http://www.flrules.org/Gateway/reference.asp?No=Ref-13975
.
(h) Florida Medicaid Provider Enrollment
				Change of Ownership (CHOW) Disclosure Form-Hospital, Institutional Care (ICF)
				and Skilled Nursing Facility ONLY, AHCA Form 5000-1264, (JAN 2021),
http://www.flrules.org/Gateway/reference.asp?No=Ref-13976
.
(i) Group Membership Authorization, AHCA Form
				5000-1061, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-13977
.
(j) Medical Foster Care Children's Medical
				Services Local Medical Foster Care (MFC) Program Care Coordinator Attestation
				Checklist, AHCA Form 5000-1069, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11337
.
(k) Non-profit Organization Certification -
				Fingerprinting Exemption, AHCA Form 5000-1261, (JAN 2021),
http://www.flrules.org/Gateway/reference.asp?No=Ref-13978
.
(l) Physician Group Certificate of Ownership,
				AHCA Form 5000-1068, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11338
.
(m) Practitioner Collaborative Agreement,
				AHCA Form 5000-1067, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11339
.
(n) Provider Agency Certification for
				Children's Services Council, AHCA Form 5000-3539, May 2014,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11340
.
(o) School District Assurance Agreement
				Provider Credentialing of Behavior Analysts, AHCA Form 5000-1162, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11341
.
(p) School District Assurance Agreement
				Provider Credentialing of Behavioral Sciences Staff, AHCA Form 5000-1160, June
				2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11342
.
(q) School District Assurance Agreement
				Provider Credentialing of Mental Health Counselors and Family Therapists, AHCA
				Form 5000-1161, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11343
.
(r) School District Assurance Agreement
				Provider Credentialing of Psychologists, Behavior Analysts, and Social Workers,
				AHCA Form 5000-1163, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11344
.
(s) School District Assurance Agreement
				Provider Credentialing of Registered Nurses and Licensed Practical Nurses, AHCA
				Form 5000-1164, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11345
.
(t) School District Assurance Agreement
				Provider Credentialing of School Health Aides, AHCA Form 5000-1165, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11346
.
(u) School District Assurance Agreement
				Provider Credentialing of Therapists and Therapy Assistants, AHCA Form
				5000-1166, June 2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11347
.
(v) Special Exempt Entity Certification -
				Fingerprinting Exemption, AHCA Form 5000-1262, (JAN 2021),
http://www.flrules.org/Gateway/reference.asp?No=Ref-13979
.
(w) State of Florida Agency for Health Care
				Administration Florida Medicaid Provider Surety Bond, AHCA Form 5000-1064, June
				2019,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11348
.
(x) Therapeutic Foster Care Provider Agency
				Self-Certification, AHCA Form 5000-3513, March 2014,
http://www.flrules.org/Gateway/reference.asp?No=Ref-11349
.