Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 33 No. 24, June 15, 2007 issue of the Florida Administrative Weekly.

These changes are in response to comments received from the Joint Administrative Procedures Committee and to comments received prior to the date of the public hearing.

59G-4.003(2). We added the effective date of May 2007 to Form UB-04 CMS-1450, Approved OMB No. 0938- 0097, and placed the word “and” before “State of Florida Abortion Certification Form.”

The rule incorporates by reference the Florida Medicaid Provider Reimbursement Handbook, UB-04, May 2007. The following changes were made to the handbook:

Page 1-3, Clean Claim. The section was rewritten to read, “In order for a claim to be paid, it must be a clean claim. Per subsection 59G-1.010(42), F.A.C., ‘clean claim’ means a claim that:

• Has been completed properly according to Medicaid billing guidelines;

• Is accompanied by all necessary documentation required by federal law, state law, or state administrative rule for payment; and

• Can be processed and adjudicated without obtaining additional information from the provider or from a third party.

A clean claim includes a claim with errors originating in the claim system. It does not include a claim from a provider who is under investigation for fraud, abuse, or violation of state or federal Medicaid laws, rules, regulations, policies, or directives, or a claim under review for medical necessity.”

Page 1-3, Out-of-State Claims Filing Limit. We corrected the section to read, “Claims submitted by out-of-state providers must be received by Medicaid or the Medicaid fiscal agent no later than 12 months from the date of service or the date of discharge to be considered for payment.”

Page 1-5, Delay in Recipient Eligibility Determination. We revised the section to read, “An exception is granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration.”

Page 1-6, Medicaid Delay in Updating Eligibility File. We revised the first sentence to read, “If Medicaid delays updating a recipient’s eligibility on FMMIS, an exception is granted.”

Page 1-6, Evaluate the Claim. We corrected the section to read, “The provider must evaluate any claim that exceeds the 12-month filing limit and determine if the claim fits any of the conditions for an exception to the 12- month filing limit.”

Page 1-9, The UB-04 Claim Form. We replaced the sample claim form with the final version, which contains the OMB approval number.

Page 1-28, Form Locator 44. We expanded the instructions for Freestanding Dialysis Centers to read, “Claims for the administration of Erythropoietin (Epogen, EPO) require the entry of the five-digit injection HCPCS code and the 11-digit National Drug Code (NDC). The first five digits of the NDC are the manufacturer’s labeler code. If the manufacturer omitted one or more leading zero from the labeler code on the package, be sure to add the leading zeros on the claim. If the NDC is only 10 digits, add a leading ‘0’ in the middle group of numbers so the claim can process. For example, if the NDC is in a 5-3-2 digit format, add a leading ‘0’ in the middle group to make it a 5-4-2 digit format.

Whenever possible, bill the claim electronically on an 837i transaction, because there is not a Form Locator on the UB-04 for the NDC. If the provider must bill on a paper claim, attach documentation with the NDC to the claim and send it to the area Medicaid office for processing.”

Page 1-49, Technical Support. In the first paragraph, second sentence, we added the time zone so the sentence reads, “The Medicaid fiscal agent’s EDI Technical Support is available to all providers Monday through Friday from 8:00 a.m. to 7:00 p.m. Eastern Time at (800)829-0218.”

Page 2-1, Prior Authorization Requirements. We revised the first sentence to read, “In order to be reimbursed by Medicaid, certain services require that providers obtain prior authorization of the services’ medical necessity per subsection 59G-1.010(166), F.A.C., before the services are performed.”

Page 2-3, Introduction. In the first paragraph, second sentence, we added, “in accordance with subsection 59G- 1.010(166), F.A.C.”

Page 2-8, Individuals with Pending Medicaid Eligibility and Medically Need Recipients. We added the following note after the last paragraph, “See Chapter 3 in the Florida Medicaid Provider General Handbook for a description of the Medically Needy Program. The Florida Medicaid Provider General Handbook is incorporated by reference in Rule 59G-5.020, F.A.C.”

Page 2-9, Retrospective Payment Review. In the first paragraph, first sentence, we added “liability” after third party so that the sentence reads, “recipients with third party liability (TPL) insurance coverage.”

Page 2-15, Medicaid Prior Authorization Unit Responsibility. We revised the second sentence to read, “The decision will be rendered within ten business days following the receipt of documentation to establish the need for the out-of-state service.”

Page 2-21, Illustration 2-2. Completed Sample Prior Authorization Request. We revised the sample to be for a procedure that requires prior authorization.

Page 2-43, Illustration 2-11. Exception to Hysterectomy Acknowledgement Requirement Form. We changed the reference on the form from the UB-92 to the UB-04.

Page 3-11, New or Photocopied Claims. We added the following definition of an AHCA priority exception claim, “An AHCA priority exemption claim is a claim that AHCA sends to the Medicaid fiscal agent for processing.”