TemplatesOwl
Homepage ↦ Fill Out Your Institutional Medicaid Provider Form
Article Structure

The Institutional Medicaid Provider form serves as a comprehensive agreement between healthcare providers and the Florida Agency for Health Care Administration, aimed at ensuring quality and compliance in the delivery of medical services to Medicaid recipients. By agreeing to this form, providers commit to offering services that are not only medically necessary but also of high quality, matching those from their peers. Importantly, they accept the obligation to adhere to federal, state, and local regulations, which governs their practice and the billing of services. This document encompasses significant aspects such as non-discrimination policies, quality assurance, and provider responsibilities, which require ongoing compliance with licensure requirements and accurate billing practices. Providers also need to maintain adequate records, report any changes in ownership, and ensure they do not engage in practices that could be deemed discriminatory. The agreement is in effect for a five-year term, with provisions for renewal, while it emphasizes the importance of accuracy and transparency in the claims process. Each provider must notify the agency about any changes and is liable for all services rendered, ensuring that quality and accountability remain at the forefront of Medicaid provisions.

Institutional Medicaid Provider Example

NON-INSTITUTIONAL

MEDICAID PROVIDER AGREEMENT

The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions:

(1)Discrimination. The parties agree that the Agency for Health Care Administration (agency) may make payments for medical assistance and related services rendered to Medicaid recipients only to an individual or entity who has a provider agreement in effect with the agency, who is performing services or supplying goods in accordance with federal, state, and local law, and who agrees that no person shall, on the grounds of sex, handicap, race, color, or national origin, other insurance, or for any other reason, be subjected to discrimination under any program or activity for which the provider receives payment from the agency.

(2)Quality of Service. The provider agrees that services or goods billed to the Medicaid program must be medically necessary, of a quality comparable to those furnished by the provider's peers, and within the parameters permitted by the provider’s license or certification. The provider further agrees to bill only for the services performed within the specialty or specialties designated in the provider application on file with the agency. The services or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting the claim.

(3)Compliance. The provider agrees to comply fully with all state and federal laws, rules, regulations, and statements of policy applicable to the Medicaid program, including the Medicaid Provider Handbooks issued by the agency, as well as all federal, state, and local laws pertaining to licensure, if required, and the practice of any of the healing arts.

(4)Term and signatures. The parties agree that this is a voluntary agreement between the agency and the provider, in which the provider agrees to furnish services or goods to Medicaid recipients. Provided that all requirements for enrollment have been met, this agreement shall remain in effect for five (5) years from the effective date of the provider’s eligibility for initial enrollment unless otherwise terminated. With respect to reenrolling providers, the agreement shall remain in effect for five (5) years from either the date the most recent agreement expires or the date the provider signs the renewal agreement, which ever date is earlier, unless otherwise terminated. This agreement shall be renewable only by mutual consent. The provider understands and agrees that no agency signature is required to make this agreement valid and enforceable.

(5)Provider Responsibilities. The Medicaid provider shall:

(a)Possess at the time of signing of the provider agreement, and maintain in good standing throughout the period of the agreement's effectiveness, a valid professional, occupational, facility or other license pertinent to the services or goods being provided, as required by the state or locality in which the provider is located, and the Federal Government, if applicable.

(b)Maintain in a systematic and orderly manner all medical and Medicaid-related records the agency requires and determines are relevant to the services or goods being provided.

(c)Retain all medical and Medicaid-related records for a period of five (5) years to satisfy all necessary inquiries by the agency.

(d)Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients and comply with all state and federal laws pertaining to confidentiality of patient information.

(e)Send, at the provider’s expense, all Medicaid-related information, which may be in the form of records, logs, documents, or computer files, and other information pertaining to services or goods billed to the Medicaid program, including access to all patient records and other provider information if the provider cannot easily separate records for Medicaid patients from other records to the Attorney General, the Federal Government, and the authorized agents of each of these entities.

Non-Institutional MPA (March 2012)

1 of 4

(f)Bill other insurers and third parties, including the Medicare program, before billing the Medicaid program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other state and federal requirements in this regard.

(g)Report and refund any moneys received in error or in excess of the amount to which the provider is entitled from the Medicaid program within 90 days of receipt.

(h)Be liable for and indemnify, defend, and hold the agency harmless from all claims, suits, judgments, or damages, including court costs and attorney's fees, arising out of the negligence or omissions of the provider in the course of providing services to a recipient or a person believed to be a recipient to the extent allowed by in and accordance with section 768.28, F.S. (2001), and any successor legislation.

(i)Provide proof of liability insurance at the option of the agency and maintain such insurance in effect for any period during which services of goods are furnished to Medicaid recipients.

(j)Accept Medicaid payment as payment in full, and not bill or collect from the recipient or the recipient's responsible

party any additional amount except, and only to the extent the agency permits or requires, co-payments, coinsurance, or deductibles to be paid by the recipient for the services or goods provided. This includes situations in which the provider’s Medicare coinsurance claims are denied in accordance with Medicaid policy.

(k)Comply with all of the requirements of Section 6032 (Employee Education About False Claims Recovery) of the Deficit Reduction Act of 2005, if the provider receives or earns five million dollars or greater annually under the State plan.

(l)Submit, within 35 days of the date on a request by the Secretary or the Medicaid agency, full and complete information about the ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.

(m)Employ only individuals who may legally work in the United States, either U.S. citizens or foreign citizens who are authorized to work in the U.S, in compliance with the Immigration Reform and Control Act of 1986 which prohibits employers from knowingly hiring illegal workers.

(n)Utilize the U.S. Department of Homeland Security’s E-Verify Employment Eligibility Verification system to verify the employment eligibility of all persons employed by the provider during the term of this Contract to perform employment duties within Florida and all persons (including subcontractors) assigned by the provider to perform work pursuant to this Contract. The provider shall include this provision in all subcontracts it enters into for the performance of work under this Contract.

(o)Attest that all statements and information furnished by the prospective provider before signing the provider agreement shall be true and complete. The filing of a materially incomplete, misleading or false application will make the application and agreement voidable at the option of the agency and is sufficient cause for immediate termination of the provider from the Medicaid program and/or revocation of the provider number.

(p)Agree to notify the agency of any changes to the information furnished on the Florida Medicaid Provider Enrollment Application including changes of address, tax identification number, group affiliation, depository bank account, and principals. For this purpose, principals includes partners or shareholders of five (5) percent or more, officers, directors, managers, financial records custodian, medical records custodian, subcontractors, and individuals holding signing privileges on the depository account, and other affiliated person.

(q)Agree to notify the agency within 5 business days after suspension or disenrollment from Medicare. Failure to notify may result in sanctions imposed pursuant s. 409.908 (24) and the provider may be required to return funds paid to the provider during the period of time that the provider was suspended or disenrolled as a Medicare provider.

(6)Agency Responsibilities. The agency shall:

(a)Make timely payment at the established rate for services or goods furnished to a recipient by the provider upon receipt of a properly completed claim.

Non-Institutional MPA (March 2012)

2 of 4

(b)Not seek repayment from the provider in any instance in which the Medicaid overpayment is attributable to error of the agency in the determination of eligibility of a recipient.

(7)Change of Ownership. A Medicaid provider agreement may be revoked, at the option of the agency, as the result of a change of ownership of any facility, association, partnership, or other entity named as the provider in the provider agreement.

(a)If the provider sells or transfers a business interest or practice that substantially constitutes the entity named as the provider in the provider agreement, or sells or transfers a facility that is of substantial importance to the entity named as the provider in the provider agreement, the provider is required to maintain and make available to the agency Medicaid- related records that relate to the sale or transfer of the business interest, practice, or facility in the same manner as though the sale or transaction had not taken place, unless the provider enters into an agreement with the purchaser of the business interest, practice, or facility to fulfill this requirement.

(b)In the event of a change of ownership, the transferor remains liable for all outstanding overpayments, administrative fines, and any other moneys owed to the agency before the effective date of the change of ownership. In addition to the continuing liability of the transferor, the transferee is liable to the agency for all outstanding overpayments identified by the agency on or before the effective date of the change of ownership. The term “outstanding overpayment” includes any amount identified in a preliminary audit report issued to the transferor by the agency on or before the effective date of the change of ownership. In the event of a change of ownership for a skilled nursing facility or intermediate care facility, the Medicaid provider agreement shall be assigned to the transferee if the transferee meets all other Medicaid provider qualifications. In the event of a change of ownership involving a skilled nursing facility licensed under part II of chapter 400, liability for all outstanding overpayments, administrative fines, and any moneys owed to the agency before the effective date of the change of ownership shall be determined in accordance with s. 400.179.

(c)At least 60 days before the anticipated date of the change of ownership, the transferor shall notify the agency of the intended change of ownership and the transferee shall submit to the agency a Medicaid provider enrollment application. If a change of ownership occurs without compliance with the notice requirements of this subsection, the transferor and transferee shall be jointly and severally liable for all overpayments, administrative fines, and other moneys due to the agency, regardless of whether the agency identified the overpayments, administrative fines, or other moneys before or after the effective date of the change of ownership. The agency may not approve a transferee’s Medicaid provider enrollment application if the transferee or transferor has not paid or agreed in writing to a payment plan for all outstanding overpayments, administrative fines, and other moneys due to the agency. This subsection does not preclude the agency from seeking any other legal or equitable remedies available to the agency for the recovery of moneys owed to the Medicaid program. In the event of a change of ownership involving a skilled nursing facility licensed under part II of chapter 400, liability for all outstanding overpayments, administrative fines, and any moneys owed to the agency before the effective date of the change of ownership shall be determined in accordance with s. 400.179 if the Medicaid provider enrollment application for change of ownership is submitted before the change of ownership.

(8)Termination for Convenience. This agreement may be terminated without cause upon thirty (30) days written notice by either party.

(9)Interpretation. When interpreting this agreement, it shall be neither construed against either party nor considered which party prepared the agreement.

(10)Governing Law. This agreement shall be governed by and construed in accordance with the laws of the State of Florida and both parties concur that this agreement is a legal and binding document and is fully enforceable in a court of competent jurisdiction.

(11)Amendment. This agreement, application and supporting documents constitute the full and entire agreement and understanding between the parties with respect to their relationship. No amendment is effective unless it is in writing and signed by each party.

(12)Severability. If one or more of the provisions contained in this agreement or application shall be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired.

Non-Institutional MPA (March 2012)

3 of 4

(13)Agreement Retention. The parties agree that the agency may only retain the signature page of this agreement, and that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record.

(14)Funding. This contract is contingent upon the availability of funds.

(15)Assignability. The parties agree that neither may assign their rights under this agreement without the express written consent of the other.

The provider, or each principal of the provider if the provider is a corporation, partnership, association, or other entity, is required to sign this agreement. For this purpose, principals includes partners or shareholders of five (5) percent or more, officers, directors, managers, financial records custodian, medical records custodian, subcontractors, and individuals holding signing privileges on the depository account, and other affiliated person. A chief executive officer (CEO) or president may sign this agreement in lieu of all principals. Failure to sign the agreement will make the agreement and provider number voidable by the agency.

The signatories hereto represent and warrant that they have read the agreement, understand it, and are authorized to execute it on behalf of their respective principals or co-owners. This agreement becomes null and void upon transfer of assets; change of ownership; or upon discovery by the agency of the submission of a materially incomplete, misleading or false provider application unless subsequently ratified or approved by the agency.

IN WITNESS WHEREOF, the undersigned have caused this agreement to be duly executed under the penalties of perjury, and now affirms that the foregoing is true and correct.

(legibly print name of signatory)

 

Title

 

Signature

 

Date

 

 

 

 

 

 

 

(legibly print name of signatory)

 

Title

 

Signature

 

Date

 

 

 

 

 

 

 

(legibly print name of signatory)

 

Title

 

Signature

 

Date

 

 

 

 

 

 

 

(legibly print name of signatory)

 

Title

 

Signature

 

Date

(ATTACH ADDITIONAL SIGNATURE PAGES IF NECESSARY)

Please complete the following information:

Provider’s Name:

DBA Name:

Tax Identification Number:

National Provider Identifier:

Florida Medicaid Identification Number:

(For new applicants, the Medicaid ID will be entered by the fiscal agent upon approval of the application.)

Non-Institutional MPA (March 2012)

4 of 4
Get Institutional Medicaid Provider PDF Form

Form Characteristics

Fact Name Detail
Non-Discrimination Providers must ensure no individual is discriminated against based on sex, race, or other factors while receiving Medicaid-funded services.
Quality of Service Services billed to Medicaid must be medically necessary and comparable to those provided by peers.
Compliance Requirements Providers must adhere to all applicable state and federal laws, including Medicaid Provider Handbooks.
Term Duration The agreement is effective for five years but can be renewable by mutual consent.
Provider Responsibilities Providers are responsible for maintaining valid licenses and keeping accurate records for at least five years.
Change of Ownership The Medicaid provider agreement may be revoked upon a change of ownership of the provider entity.
Termination Clause The agreement can be terminated without cause by either party with a 30-day written notice.
Governing Law This agreement is governed by the laws of the State of Florida and is binding in a court of law.

Guidelines on Utilizing Institutional Medicaid Provider

Filling out the Institutional Medicaid Provider form involves providing accurate and complete information to comply with Medicaid regulations. Following these steps will help ensure that the form is submitted correctly, paving the way for the establishment of your provider agreement.

  1. Begin by clearly writing the Provider’s Name in the specified field.
  2. Next, enter any Doing Business As (DBA) Name if applicable.
  3. Provide the Tax Identification Number in the outlined section.
  4. Fill in your National Provider Identifier.
  5. Complete the field for the Florida Medicaid Identification Number. For new applicants, leave this blank; it will be filled in by the fiscal agent once the application is approved.
  6. Review all entered information for accuracy to avoid delays.
  7. Sign the form in the required signatory section, making sure to include the date of signing.
  8. If applicable, ensure that additional professionals also sign on the provided signature pages.
  9. Once completed, submit the form as directed in the application instructions.

What You Should Know About This Form

What is the purpose of the Institutional Medicaid Provider form?

The Institutional Medicaid Provider form serves as an agreement between healthcare providers and the Florida Medicaid program. This document outlines the terms and conditions under which treatment, goods, and services are provided to Medicaid recipients. It establishes the provider's eligibility and ensures compliance with federal and state laws governing Medicaid services.

What are the main responsibilities of a Medicaid provider?

A Medicaid provider is required to fulfill several responsibilities. First, they must maintain a valid professional license pertinent to their services. They are responsible for ensuring that all services billed to Medicaid are necessary and provided according to state and local laws. Moreover, providers must safeguard patient information and maintain accurate records for at least five years. They must also comply with billing procedures, such as billing other insurers before Medicaid and reporting overpayments within a specified timeframe.

How long does the agreement remain in effect?

The Medicaid provider agreement remains in effect for five years from the date of initial enrollment or from the expiration of the previous agreement, in cases of re-enrollment. The agreement can be renewed, but only with mutual consent between the provider and the agency. It is crucial for providers to understand the renewal process to avoid lapses in their agreement.

What happens if a provider fails to comply with the agreement?

If a provider fails to comply with the terms of the agreement, the agency has the authority to terminate the provider's participation in the Medicaid program. This includes situations where the provider submits false or incomplete information during the application process. Additional sanctions may also apply, which can result in the provider being required to return any funds received during the period of non-compliance.

How should a change of ownership be reported for a Medicaid provider?

In the event of a change of ownership, the current provider must notify the agency at least 60 days prior to the anticipated change. The new owner must also submit a Medicaid provider enrollment application. Failure to comply with these requirements can result in joint liability for any outstanding payments or fines, even if the change occurs after the notification period. Proper documentation must be maintained to satisfy any inquiries related to the ownership change.

Common mistakes

When filling out the Institutional Medicaid Provider form, people often make several critical mistakes that can delay the approval process or even lead to rejection. One common error is failing to provide complete information. The application requires detailed responses, including any changes to the provider's business and ownership structure. Missing this information can cause unnecessary roadblocks.

Another mistake is not keeping track of the required documentation. Providers must supply proof of relevant licenses and certifications. If this documentation is missing or incomplete, it will result in delays. It’s essential to double-check all documents before submission to ensure compliance.

Misunderstanding the billing requirements is also a frequent issue. Providers are obligated to bill other insurances before submitting a claim to Medicaid. Failing to do so can lead to denial of reimbursement and could possibly result in financial losses for the provider. Keeping up-to-date with billing protocols is crucial.

Compliance with all applicable laws is a critical requirement. Some providers overlook the importance of understanding state and federal regulations related to Medicaid. A lack of familiarity can lead to significant errors that may jeopardize their status as a provider. Continuous education and awareness of relevant laws can help mitigate this risk.

Lastly, providers often neglect the importance of signatures on the document. Each principal involved must sign the agreement to validate it. Missing or unsigned documents can render the entire application void. It’s important to ensure that all necessary signatures are obtained before submission to avoid disappointing delays.

Documents used along the form

The Institutional Medicaid Provider form is just one part of the documentation required to participate in the Florida Medicaid program. Along with it, several other forms and documents are frequently needed to ensure compliance with state and federal regulations. Each of these documents serves a specific purpose, and understanding them can simplify the application and enrollment process.

  • Medicaid Provider Enrollment Application: This application is required for any provider seeking to enroll in the Medicaid program. It gathers essential information about the provider's qualifications, services offered, and any relevant licenses.
  • Florida Medicaid Provider Handbook: This handbook outlines the rules and regulations that providers must follow when billing and providing services to Medicaid recipients. It serves as a vital reference to ensure compliance.
  • Proof of Liability Insurance: Providers may need to submit evidence of liability insurance to cover any potential claims arising from the provision of services to Medicaid recipients.
  • W-9 Form: This form provides the provider's taxpayer identification number, which is necessary for tax purposes and payment processing from Medicaid.
  • Medicaid Recipient Eligibility Verification: Providers must verify that patients are eligible for Medicaid services. This document confirms that the patient meets the criteria outlined by the Medicaid program.
  • History of Business Ownership: In cases where a provider's business has changed ownership, documentation detailing the history of ownership may be necessary to ensure continuity and accountability.
  • Ownership Disclosure Information: Providers are required to disclose any ownership interests in other entities. This document helps Medicaid ensure transparency and prevent conflicts of interest.
  • Certificate of Good Standing: This certificate, issued by the state, confirms that the provider's business is in compliance with all regulations and is authorized to operate.
  • Employee Education About False Claims Recovery Documentation: If applicable, providers must demonstrate compliance with training employees about the implications of false claims under the Deficit Reduction Act.

Gathering these documents before applying can streamline the enrollment process and reduce the likelihood of delays. Each document has its significance and contributes to a thorough understanding of the obligations and responsibilities associated with being a Medicaid provider. Proper compliance not only benefits the provider but also enhances the care delivered to Medicaid recipients.

Similar forms

The Institutional Medicaid Provider form has some key similarities with several other important documents in the healthcare system. Here’s a closer look at those documents:

  • Medicaid Provider Enrollment Application: Like the Institutional Medicaid Provider form, this application outlines the terms under which healthcare providers can enroll in the Medicaid program. It collects essential information about the provider, including qualifications and services offered, ensuring compliance with state and federal law.
  • Non-Profit Organization Agreement: This agreement is similar in that it requires non-profit healthcare providers to commit to certain conditions of service and ethical standards. Just as providers must adhere to quality and non-discrimination clauses in the Medicaid form, non-profit agreements stress the importance of serving vulnerable populations without discrimination.
  • Health Insurance Portability and Accountability Act (HIPAA) Compliance Agreement: Much like the Medicaid Provider form, this agreement emphasizes the importance of confidentiality and the ethical handling of patient records. Both documents prioritize safeguarding sensitive patient information against unauthorized access.
  • Medicare Provider Agreement: This document is closely aligned with the Institutional Medicaid Provider form in its purpose. It details the responsibilities and rights of healthcare providers participating in Medicare, including conditions for billing, compliance with federal regulations, and requirements for record-keeping.

Dos and Don'ts

When filling out the Institutional Medicaid Provider form, keep the following recommendations in mind:

  • Read all instructions carefully. Understand each section before you begin filling it out.
  • Provide accurate information. Verify that all details, such as your tax identification number, are correct.
  • Maintain compliance. Familiarize yourself with relevant state and federal laws to ensure adherence.
  • Keep records organized. Systematically maintain all medical and Medicaid-related records for at least five years.
  • Notify promptly. Inform the agency of any changes, such as address or ownership status, within the required timeframe.
  • Bill other insurers first. Ensure you bill any other applicable insurance before approaching Medicaid.
  • Verify employment eligibility. Use the E-Verify system for all employees assigned to Medicaid services.
  • Avoid errors. Do not file an application with incomplete, misleading, or false information.

By following these guidelines, you can navigate the application process more effectively and comply with Medicaid requirements.

Misconceptions

  • Misconception 1: Institutional Medicaid providers do not need to maintain any licenses or certifications.

    This is not true. Providers must possess and maintain in good standing a valid professional, occupational, or facility license relevant to their services.

  • Misconception 2: All providers automatically qualify for Medicaid reimbursement.

    In reality, providers must have an active provider agreement, meet eligibility criteria, and comply with several regulations to be reimbursed.

  • Misconception 3: Medicaid providers can bill recipients for any amount beyond Medicaid reimbursement.

    This is incorrect. Providers can only charge co-payments, coinsurance, or deductibles allowed by Medicaid, and cannot bill additional amounts without permission.

  • Misconception 4: Providers are not responsible for overpayments they receive from Medicaid.

    Providers must report and refund any overpayments or erroneous funds within 90 days. Failing to do so can lead to serious consequences.

  • Misconception 5: There are no reporting obligations regarding ownership changes.

    This is a misconception. Providers must notify the agency at least 60 days prior to a change of ownership and comply with specific reporting requirements.

Key takeaways

Filling out and using the Institutional Medicaid Provider form is an essential process for healthcare providers looking to participate in the Florida Medicaid program. Here are some key takeaways to help navigate this important procedure:

  • The provider agreement must be in effect with the Florida Agency for Health Care Administration to enable payment for medical assistance and related services.
  • All services billed to Medicaid should be medically necessary and performed within the provider’s licensed specialties.
  • Compliance with both state and federal regulations, including the Medicaid Provider Handbooks, is mandatory for all providers.
  • Providers are responsible for maintaining comprehensive medical and Medicaid-related records for five years to address inquiries from the agency.
  • Providers must bill other insurance entities before charging Medicaid. This could include Medicare if eligible.
  • It is vital to report any errors in moneys received from Medicaid within 90 days, including returns for excess funds.
  • A change of ownership for a provider may revoke the Medicaid provider agreement unless proper notification and enrollment procedures are followed.
  • Termination of the agreement can occur without cause by either party, with a written 30-day notice.

Understanding these points can fortify a healthcare provider’s ability to successfully navigate the Medicaid enrollment process. Ensuring all aspects of the agreement are honored is crucial for maintaining compliance and securing reimbursement for services rendered.

Browse Other Templates

Dol Form 5500 - Schedules include important disclosures about plan management.

Basic College Math - Green Applications align mathematics with environmental contexts, fostering relevant learning.