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The Institutional Medicaid Provider form is a critical document that outlines the relationship between healthcare providers and the Florida Medicaid program. This agreement ensures that services rendered to Medicaid recipients are both necessary and compliant with various laws. One significant aspect includes the provider's commitment to avoid discrimination, guaranteeing that all individuals receive equitable treatment regardless of their characteristics. The form also emphasizes the importance of delivering high-quality services and adhering to established medical standards, specified licenses, and appropriate specialties. Compliance is a central theme, as providers must follow rigorous state and federal regulations, thereby safeguarding the integrity of the Medicaid system. The structure of the agreement allows for a five-year term, subject to renewal under specific conditions, ensuring continuity in service provision. Providers are also held responsible for maintaining detailed medical records and transparency in billing practices, including prior insurance claims. Furthermore, the form's stipulations cover various administrative aspects, such as responsibilities during changes of ownership, the processes for termination and amendment of the agreement, and the overall legal framework governing this relationship. Collectively, these elements underscore the form’s role in ensuring that Medicaid recipients receive proper and lawful healthcare services while holding providers accountable to established standards.
Institutional Medicaid Provider Example
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
(c)Retain all medical and
(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
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(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,
(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
(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
(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.
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(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.
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(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
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.
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(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.)
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File Breakdown
| Fact Name | Details |
|---|---|
| Provider Agreement Requirement | Providers must have a valid provider agreement with the Agency for Health Care Administration to receive payments for services. |
| Duration of Agreement | The agreement lasts for five years, renewable by mutual consent, unless terminated earlier. |
| Compliance Obligations | Providers must comply with all relevant state and federal laws, including those in the Medicaid Provider Handbooks. |
| Termination Clause | Either party may terminate the agreement without cause upon providing a 30-day written notice. |
| Governing Laws | This agreement is governed by the laws of the State of Florida, specifically Section 409.908 (24) and Section 768.28, F.S. |
Guide to Using Institutional Medicaid Provider
Completing the Institutional Medicaid Provider form is an essential step for providers looking to participate in the Florida Medicaid program. Ensure that all information is accurate, as errors can delay your application process.
- Begin by entering the Provider’s Name at the designated line.
- If applicable, fill in the DBA Name (Doing Business As) next to the Provider’s Name.
- Provide your Tax Identification Number in the appropriate section.
- Enter your National Provider Identifier (NPI) number.
- For new applicants, leave the section for Florida Medicaid Identification Number blank. This will be filled in by the fiscal agent upon approval of your application.
- Ensure that all entries are legible and double-check for accuracy.
- Sign and date the form at the designated line for signature, including printing your name and title.
- If more than one person is required to sign, attach additional signature pages as needed.
Get Answers on Institutional Medicaid Provider
What is the Institutional Medicaid Provider form?
The Institutional Medicaid Provider form is an agreement that allows healthcare providers to participate in the Florida Medicaid program. This form outlines the responsibilities and expectations for both the provider and the Agency for Health Care Administration. It focuses on aspects such as compliance with federal and state laws, ensuring quality of service, and preventing discrimination in the provision of medical assistance to eligible recipients.
Who can apply for the Institutional Medicaid Provider agreement?
Eligible applicants include individual healthcare providers, corporate entities, and facilities that offer medical services. Each applicant needs to hold a valid professional or occupational license pertinent to the services provided. Additionally, all applicants must comply with federal, state, and local laws relevant to the practice of their profession. It is crucial that the services billed to Medicaid are medically necessary and that the provider adheres to the standards established in the agreement.
What are the main responsibilities of a Medicaid provider?
- Maintain a valid and active professional license.
- Retain all medical records for five years and ensure they are systematic and orderly.
- Bill other insurers prior to charging Medicaid when applicable.
- Report any errors in received funds within 90 days.
- Safeguard patient confidentiality and follow laws regarding information disclosure.
How long does the Medicaid provider agreement last?
The agreement remains effective for five years, starting from the date the provider is eligible for enrollment. For those who are reenrolling, the duration is five years from either the expiration of the previous agreement or from the signing of a renewal agreement, depending on whichever date is earlier. This agreement can be renewed only with mutual consent from both parties.
What happens in case of non-compliance with the agreement?
If a provider fails to uphold the terms set forth in the Institutional Medicaid Provider form, several consequences may follow. The agency can terminate the agreement and potentially revoke the provider's Medicaid number. Furthermore, any deceptive actions or submission of false information can result in immediate termination from the Medicaid program. It is essential to remain compliant with all aspects of the agreement to prevent such drastic outcomes.
Is there a process for changing ownership of a Medicaid provider?
Yes, if there is a change of ownership within a company or facility that is a Medicaid provider, notification must be given to the agency at least 60 days before the anticipated change. The new owner must also submit a Medicaid provider enrollment application. Both the transferor and transferee will remain liable for any outstanding payments or fines due to Medicaid. Failure to comply with these requirements can result in joint liability for debts related to the program.
Common mistakes
When filling out the Institutional Medicaid Provider form, attention to detail is crucial. One common mistake is omitting required information. Applicants often overlook key sections, such as their Tax Identification Number or the National Provider Identifier. Missing details can delay the approval process or even lead to outright rejection of the application.
Another frequent issue arises from inaccurate data entry. Applicants may accidentally transpose numbers or miswrite their names. Even minor errors can create significant hurdles later on, impacting the provider's ability to receive payments or renew agreements.
Additionally, some providers fail to update their information when changes occur. A provider’s address, ownership details, or changes in professional standing must be communicated promptly. Failure to do so can result in misunderstandings or complications when submitting claims.
Providers also tend to ignore the importance of compliance with state and federal laws. Not adhering to regulations outlined in the agreement may lead to penalties or even loss of status as a Medicaid provider. It is essential to understand and follow these regulations closely.
Moreover, some individuals do not grasp the necessity of maintaining proper documentation. Medical records and Medicaid-related documentation must be kept systematically and for a minimum of five years. Lack of adequate records can jeopardize compliance and lead to complications with audits.
Another oversight is related to the contract signatures. Incomplete signatures or those from unauthorized persons can render the agreement void or voidable. Ensuring that the right individuals sign the contract is essential for its validity.
Additionally, providers may neglect to fully understand the discrimination clause included in the agreement. It is vital to ensure compliance with all anti-discrimination laws when offering services. Ignoring these stipulations can lead to serious legal consequences.
Some providers may also fail to take the termination clauses into account, which can result in confusion if the agency or provider decides to end the agreement. Understanding the conditions of termination can prevent unexpected interruptions in service.
Lastly, misunderstanding the billing procedures can be detrimental. Providers should always bill other insurances before billing Medicaid. Missteps in this area can result in financial loss and complications with future claims.
Documents used along the form
The Institutional Medicaid Provider form plays a crucial role in facilitating healthcare services for eligible individuals. However, to ensure a seamless process, several other documents often accompany it. Each of these forms serves a specific purpose, contributing to the overall management of Medicaid provider enrollment and services.
- Florida Medicaid Provider Enrollment Application: This application gathers essential information about the healthcare provider, including their qualifications, specialties, and proposed services. It is the foundational document for enrolling in the Florida Medicaid program.
- Medicaid Provider Handbook: This handbook outlines the rules, regulations, and guidelines governing the Medicaid program. It serves as a reference for providers to understand their responsibilities and comply with state and federal laws.
- Provider Assurance Form: This form is used to confirm that the provider adheres to specific quality standards and ethical guidelines. It assures the Florida Medicaid Agency that the provider is committed to delivering safe and effective care.
- Disclosure of Ownership and Control Interest Statement: Providers must submit this document to provide transparency about their ownership structure. It helps the Medicaid agency ensure that all providers meet necessary regulatory requirements.
- Certificate of Insurance: This certificate confirms that the provider carries valid liability insurance coverage. Maintaining insurance is essential for protecting both the provider and Medicaid recipients during service provision.
- Claims Submission Forms: These forms are used by providers to request payment from Medicaid for services rendered. Accurate completion is crucial for timely reimbursements and compliance with billing requirements.
- Staff Credentialing Documentation: These documents verify the qualifications and competencies of the provider's staff. Credentialing is critical to ensure that all personnel meet the standards set by Medicaid and other regulatory bodies.
- Record Retention Policy: Providers must have a documented policy outlining how long they will retain patient records and Medicaid-related documents. This policy ensures compliance with legal requirements regarding record keeping.
- Exit Notification Form: Should a provider decide to discontinue services, this form must be completed to notify Medicaid of the termination. It helps facilitate a smooth transition for patients and services.
This array of documents supports the effective functioning of the Medicaid program and ensures that providers comply with necessary regulations. Keeping them organized and readily available is essential for healthcare providers working with Medicaid services.
Similar forms
The Institutional Medicaid Provider form is a critical document within the Medicaid program framework. Understanding similar documents can provide clarity on the operational requirements and expectations for providers. Below are eight documents that share similarities with the Institutional Medicaid Provider form, along with a brief explanation of these likenesses:
- Non-Institutional Medicaid Provider Agreement: Like the Institutional Medicaid Provider form, this document outlines terms and conditions for providers delivering services to Medicaid recipients, emphasizing compliance with laws and quality of care.
- Medicaid Provider Enrollment Application: This application is the precursor to the provider agreement, assessing applicant qualifications and ensuring they meet the necessary criteria to participate in the Medicaid program.
- Medicaid Provider Handbook: Similar in content, this handbook serves as a guide to all rules and policies that Medicaid providers must follow, akin to the requirements laid out in the provider agreement.
- Medicaid Claims Submission Guidelines: These guidelines detail the processes and requirements for billing Medicaid, mirroring the financial responsibilities indicated in the provider agreement.
- Medicaid Auditing Policies: These policies share a connection with the provider form by outlining the standards and procedures for auditing provider billing practices, ensuring accountability and compliance.
- Provider Code of Conduct: This document complements the provider agreement by setting forth expected behaviors and ethical standards for Medicaid providers in their interactions with clients and the agency.
- Provider Termination and Disqualification Policies: These policies relate to the consequences of non-compliance with the terms of the provider agreement, offering clarity on potential penalties and discharge from the program.
- Professional License Verification Forms: Similar in their focus, these forms ensure that providers hold the necessary licenses to deliver services, affirming adherence to both state and federal regulations required by the provider agreement.
Understanding these documents can demystify the processes surrounding Medicaid provider agreements and foster compliance and accountability in service delivery. Each document plays a role in ensuring that quality, non-discriminatory healthcare services are accessible to qualifying recipients.
Dos and Don'ts
When filling out the Institutional Medicaid Provider form, there are some important guidelines to keep in mind. Here’s a list of things you should and shouldn't do:
- Do ensure that all the information you provide is accurate and up-to-date.
- Do check for any discrepancies or missing information before submitting the form.
- Do maintain your professional licenses in good standing throughout the enrollment period.
- Do familiarize yourself with the state and federal laws that apply to Medicaid providers.
- Don't falsify or misrepresent any information on your application.
- Don't forget to report any changes in your personal or business information promptly.
- Don't ignore any instructions from the Medicaid agency regarding documentation or billing.
- Don't delay in notifying the agency if you experience any changes in your Medicare enrollment status.
Misconceptions
Misconception 1: The Institutional Medicaid Provider form is a fixed document that does not require updates.
This is incorrect. The agreement is subject to change and requires providers to notify the agency of any alterations in their information, including changes in address or ownership structure.
Misconception 2: All providers automatically qualify once they submit the Institutional Medicaid Provider form.
In reality, providers must meet specific eligibility requirements and obtain necessary licenses. A submission alone does not guarantee participation in the Medicaid program.
Misconception 3: The agreement remains valid indefinitely once signed.
This is misleading. The agreement lasts for five years and must be renewed or will otherwise terminate based on specific conditions outlined in the form.
Misconception 4: Medicaid providers can charge recipients additional fees beyond allowed co-payments.
This is false. Providers are required to accept Medicaid payments as full compensation for services, with limited exceptions for co-payments and specific circumstances clearly defined.
Misconception 5: There are no penalties for failing to comply with the terms of the agreement.
This is incorrect. Non-compliance can lead to serious consequences, including termination from the program and potential legal action for outstanding overpayments.
Key takeaways
When preparing the Institutional Medicaid Provider form, there are several important factors to consider to ensure compliance and smooth operation. Here are four key takeaways:
- Understand Non-Discrimination Policies: The agreement emphasizes that providers must not discriminate against Medicaid recipients based on factors such as race, sex, or national origin. This commitment to equity is crucial for maintaining compliance.
- Focus on Quality Services: Providers are required to deliver services that are medically necessary and comparable to the standards upheld by their peers. It's important that claims submitted for payment only reflect the services actually provided to eligible recipients.
- Compliance with Legal Standards: Adhering to state and federal regulations is a must for any provider. This includes understanding the Medicaid Provider Handbooks and any relevant local laws related to licensure and practice.
- Responsibilities Are Essential: Providers need to keep accurate records, bill appropriately, and notify the agency of any changes in their operations or compliance. Accountability plays a vital role in the successful execution of Medicaid services.