Out-of-State Provider Enrollments QRG

Out-of-State Enrollment

Florida Medicaid will reimburse out-of-state providers who offer services to an eligible Medicaid recipient, under specific stipulations.  To enroll, providers must submit the application, along with required supporting documentation to Florida Medicaid Provider Enrollment, P.O. Box 7070, Tallahassee, FL 32314-7070.

The following out-of-state providers must enroll using the online Florida Medicaid Enrollment Wizard.

• Durable medical equipment and supplies entities enrolling as Medicare Crossover-Only providers.
• Fully licensed physicians in Florida that interpret diagnostic testing results from an out-of-state location through telecommunications and information technology.
• Independent laboratories certified under the Clinical Laboratory Improvement Amendments.
• Medical supply and durable medical equipment (DME) providers and pharmacies that supply items that are not otherwise available from providers located within Florida (Requires prior approval to enroll from the State of Florida, Agency for Health Care Administration).
  • Providers can directly email PharmacyPolicy@ahca.myflorida.com to find out if they are the sole source of limited distribution drugs not available from other providers enrolled in Florida Medicaid.

Out-of-State Enrollment Basics

Providers can access the Out-of-State Provider Enrollment Application. To enroll, the out-of-state provider must submit the following documents to Florida Medicaid Provider Enrollment:

• A completed Florida Medicaid Out-of-State Provider Enrollment Application
• The appropriate Florida Medicaid Provider Agreement (Institutional or Non-Institutional)
• A voided check or letter on a bank letterhead to certify the routing and account numbers provided in the EFT section.
• Copy of professional license
• Claim form
• Documentation that the claim meets one of the criteria above

If the service was eligible for reimbursement, the provider will be enrolled retroactively for the dates on which the service was provided.

Completing the Out-of-State Provider Application

All fields marked with and asterisk (*) are required for completion of the application. Fields marked with a carat (^) must be completed as applicable. Providers must select a reason for submission and must include supporting documentation for the reason selected.

Enrollment Type

Enter Provider Type, Specialty Type, and Taxonomy.

Identifying Information

Provider Name
This name must match exactly as registered with Internal Revenue Service (IRS) and on any professional or facility license. Enter the name of the entity or the last name, first name, and middle initial of an individual.

Tax ID Information
Social Security Number (SSN) - Individual providers who are not personally incorporated will enter their Social Security Number (SSN) and supply a copy of their Social Security card.

Federal Employer Identification Number (FEIN) - Enter your FEIN if you are an entity or are individually incorporated. Attach a legible copy of proof of tax ID such as an IRS Form SS-4, 1072, 147c, or W-9 to verify ownership of the tax ID.

Individual providers may not use their employer’s tax id on their individual provider file.

Medicaid ID Information
Providers must furnish Medicaid ID information for state of operation.

NPI Type
Florida Medicaid uses the NPI, Taxonomy, and ZIP +4 submitted in electronic or paper claims to map the provider to their Florida Medicaid provider ID. All claims must include the NPI, Taxonomy, and ZIP+4 as entered above to support successful processing

License/Permit Information
License information must be entered, as well as a legible copy submitted with the application.

Addresses

Service Location address is the complete address including county of the location where services are rendered. P.O. Boxes and mail drop locations are not accepted.

Payment Address

The payment address is where special payments and tax documents (IRS Form, 1099-Misc, etc.) are sent.

General Correspondence

The General Correspondence address is the mailing address.

Home or Corporate Office Address

Providers are given the option to enter new address details or select a previously entered location.

Ownership Interest and Managing Control

Organization

This section is to be completed with information that has direct or indirect ownership of a partnership interest in, and/or managing control of the provider. If there is more than one organization, copy and complete this section for each.

Individual 

This section is to be completed with information about any individual who has direct or indirect ownership of a partnership interest in, and/or managing control of the provider identified in the provider. If there is more than one (1) individual, copy and complete this section for each. All individuals must be fingerprinted. Information on background screening can be found on the Enrollment page under Background Screening.

Out-of-state providers and owners/operators of business entities who are known to PECOS (Medicare’s provider enrollment database) are permitted to utilize their approved statuses in the PECOS system to meet Florida Medicaid’s provider background screening requirements.

Contacts

General

Providers are to complete this section with the information for the individual whom they have selected as a contact person. This will be the contact person that Florida Medicaid corresponds with regarding the application. 

Medical Records Custodian

The individual chosen as the general contact may also serve as The Medical Records Custodian. If different, information is to be filled for the Medical Records Custodian that the provider has chosen. If the same as the general contact, the provider is to check the Same as Contact Person box provided, then proceed with the application.

Financial Records Custodian

The individual chosen as the general contact or the selected individual for the Medical Records Custodian may also serve as the Financial Records Custodian. If different, information is to be filled for the Financial Records Custodian that the provider has chosen. If the same as the general contact or the Medical Records Custodian, the provider is to check the Same as Contact Person or Same as Medical Records Custodian box provided, then proceed with the application.

Contacts Electronic Funds Transfer Agreement

Provider Identifier and financial institution information is to be entered to be used by Florida Medicaid.

Submission Information

The Individual (s) listed in this section are authorized by the provider or its agent to initiate, modify, or terminate an EFT enrollment.

Certification Statement

When completing the Certification Statement, please be sure that it is completed by an individual that is listed in the Ownership Interest and Managing Control Information section of the application.

Additional Resources
AHCA Adopted Rules
Adopted Rules - Florida Medicaid Forms
Adopted Rules - Provider Enrollment Policy
Florida Medicaid Contact Information Sheet
Provider Support Resources
Training

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