Fla. Admin. Code R. 59H-1.010

Current through Reg. 50, No. 235-239, December 10, 2024

Section 59H-1.010 - Reimbursement Procedures

(1) The hospital shall use the universal hospital claim form, UB 04/CMS-1450, to submit claims to the county for eligible individuals who received covered hospital care.

(2) Each county shall designate an office or agency that will pay claims. The name, title, address, and phone number of the person or county agency, which shall process claims under the act shall be provided to the Agency on an annual basis, and when modified. The county is responsible for informing the Agency of any changes to this information within 30 calendar days of such change. The Agency shall provide such information to the participating hospitals and regional referral hospitals on an annual and modified basis.

(3) The hospital shall submit the completed claim and a copy of the notification of eligibility to the resident county office designated to pay claims within 6 months of the date of the notice of eligibility. Failure to receive a claim within 6 months may result in rejection of the claim at the option of the county.

(4) The county shall reimburse the hospital within 90 calendar days of receipt of a claim, unless the claim is disputed under the provisions of Chapter 120, F.S. In cases where the patient becomes eligible for third party payment, disability benefits or other state or federal benefits, the hospital shall reimburse the county for any overpayment by the county within 60 calendar days of receipt of such payment from any other source. In cases where the hospital has received overpayment on a claim(s), the hospital shall reimburse the county for any overpayment within 60 calendar days of receipt of such notification. If the due date falls on a weekend or holiday, the reimbursement deadline is the next business day. Overpayment is an adjustment of charges, including credit balance resulting from a payment made by an insurance carrier or another responsible party, duplicate payment, reimbursement calculation error (as examined by one or more individuals with either the county, hospital or Agency and determined to have been paid in error based on the review of documentation supporting the claim), or misapplied charges or credits.

(5) In cases where payment is made to a hospital for a spend-down provision eligible applicant and no third party payor or other government program is involved, the total payment to the hospital shall not exceed the Medicaid reimbursement rate, or other negotiated rate, minus the applicant's share of cost.

(6) The county shall provide the agency, if requested, a copy of the claim for which payment is made or denied, indicating disposition and date.

Fla. Admin. Code Ann. R. 59H-1.010

Rulemaking Authority 154.3105 FS. Law Implemented 154.306, 154.314 FS.

New 3-29-89, Amended 2-24-92, Formerly 10C-26.010, Amended 6-7-00, Amended by Florida Register Volume 42, Number 154, August 9, 2016 effective 8/25/2016.

New 3-29-89, Amended 2-24-92, Formerly 10C-26.010, Amended 6-7-00, 8-25-16.