Florida Medicaid is administered by the Agency for Health Care Administration (AHCA) and operates primarily through a mandatory managed care system called Statewide Medicaid Managed Care (SMMC). Nearly all Florida Medicaid beneficiaries are enrolled in a managed care plan rather than fee-for-service AHCA directly. Our Florida Medicaid billing services handle all SMMC plans across the state.
A provider who is credentialed with AHCA is not automatically credentialed with every managed care plan. Each plan operates as a separate payer with its own provider enrollment, fee schedule, and medical policies. Our Medicaid credentialing services manage enrollment with AHCA and each managed care plan separately.
How Florida Statewide Medicaid Managed Care Works
Florida SMMC divides Medicaid services into the Managed Medical Assistance (MMA) program for most physical and behavioral health services, and the Long-Term Care (LTC) program for nursing facility and home and community-based services. Each MMA plan contracts with AHCA but operates its own provider network and processes claims according to its own rules. Our payer-specific billing services handle each SMMC plan independently.
EPSDT Billing for Pediatric Medicaid Patients
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit applies to all Medicaid beneficiaries under age 21 in Florida. It requires coverage of any medically necessary service for these patients. EPSDT screenings use specific CPT codes for well-child visits and include vision, hearing, dental, and developmental assessments. Our medical coding services ensure correct EPSDT code selection.
Prior Authorization Under Florida Medicaid Plans
Each SMMC managed care plan maintains its own prior authorization requirements. Services that do not require PA under fee-for-service AHCA may require PA under a specific managed care plan. Prior authorization requests are submitted directly to the managed care plan, not to AHCA. Our prior authorization services maintain payer-specific PA protocols for each Florida Medicaid managed care plan.
Provider Enrollment for Florida Medicaid
To bill Florida Medicaid fee-for-service, providers must enroll through the Florida Medicaid Management Information System (FMMIS), available through the Florida Medicaid provider portal. To bill a Medicaid managed care plan, providers must also be credentialed and contracted with each specific plan. Our Medicaid credentialing services manage both AHCA enrollment and managed care plan contracting simultaneously.
Key Takeaways
- Most Florida Medicaid patients are in SMMC managed care plans, not fee-for-service AHCA directly.
- Credentialing with AHCA does not substitute for enrollment with each individual Medicaid managed care plan.
- Prior authorization requirements vary by plan and must be verified for each managed care organization.
- EPSDT requires coverage of any medically necessary service for Medicaid patients under age 21.
- Our Florida Medicaid billing and Medicaid credentialing services handle the complete enrollment and billing workflow.
Frequently Asked Questions
How do I find out which Medicaid plan a Florida patient is enrolled in?
AHCA provides a recipient eligibility verification system through the Florida Medicaid Web Portal. Our eligibility verification services perform this check for every Florida Medicaid patient before each visit.
Can a Florida provider bill AHCA fee-for-service for a managed care plan patient?
No. When a patient is enrolled in an SMMC managed care plan, the claim must be submitted to that plan, not to AHCA directly. AHCA will deny claims for patients who are covered by a managed care plan at the time of service. Our Florida Medicaid billing services route every claim to the correct plan.
Does Florida Medicaid cover telehealth?
Yes. Florida Statutes Section 456.47 requires coverage of telehealth services by Medicaid managed care plans. Our payer-specific billing team maintains current telehealth rules for each Florida Medicaid plan.