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Hurricane Michael Emergent Claims Processing

Important provider information regarding reimbursement for services rendered to Prestige Health Choice members impacted by Hurricane Michael.

October 22 – Disaster grace period update

The Agency is extending the disaster grace period for Hurricane Michael from October 22 through November 9, 2018, for the following twelve counties that the Federal Emergency Management Agency (FEMA) has designated as a major disaster area: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Leon, Liberty, Taylor, Wakulla, and Washington.

Extended disaster grace period: October 22, 2018, to November 9, 2018, for the 12 counties listed above.

  • No prior authorizations are required for any inpatient or outpatient services.
  • Payment will be provided to both participating and non-participating providers for services provided to Prestige Health Choice members during this period.
  • Services will be provided whether or not the enrollee has temporarily relocated to a different region or state.
  • Usual service limitations will not be applied during this period.
  • Payment will be provided to mobile pharmacies in FEMA-designated counties when all the requirements stated in the Department of Health Emergency Order 18-276 are met and when the mobile pharmacy is one of the following:
    • A participating pharmacy network provider and is known to Florida Medicaid.
    • A non-participating provider but is currently a Medicare-participating provider and is provisionally enrolled in the Florida Medicaid program.
  • In order to be reimbursed for eligible Prestige Health Choice members for dates of service within this period, providers not already enrolled in Florida Medicaid (out of state or in state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at the Agency for Health Care Administration (AHCA) Hurricane Michael information page. Please refer to the Provisional Provider Enrollment section below for additional information.

Disaster grace period: October 7, 2018, through October 21, 2018, for all counties under state of emergency.

  • No prior authorizations are required for any inpatient or outpatient services.
  • Payment will be provided to both participating and non-participating providers for services provided to Prestige Health Choice members during this period.
  • Usual service limitations will not be applied during this period.
  • In order to be reimbursed for eligible Prestige Health Choice members for dates of service within this period, providers not already enrolled in Florida Medicaid (out of state or in state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at the Agency for Health Care Administration (AHCA) Hurricane Michael information page. Please refer to the provider provisional enrollment section below for additional information.

Starting November 10, 2018, prior authorizations will be reinstated for inpatient and outpatient services for the 12 counties listed above. Prior authorizations have been reinstated for all other counties as of October 22, 2018.

For the 12 counties listed above, starting with date of service November 10, 2018, new authorization requests for durable medical equipment (DME) and home health services will be reviewed as part of an expedited authorization process until further notice. This expedited authorization process will be completed within forty-eight (48) hours after receipt of the request for service. Prestige Health Choice may extend the timeframe for expedited authorization decisions by up to two (2) business days if the member or the provider requests an extension or if additional information is needed to process the request, and the extension is in the member’s best interest.

Outside of the disaster grace period (beginning November 10, 2018, until further notice, for the 12 counties listed above. This period begins October 22, 2018, for all other counties under the state of emergency).

In those instances where a provider and/or member could not comply with policy requirements because of ongoing storm-related impact, Prestige Health Choice will continue to reimburse for:

In those instances where a provider and/or member could not comply with policy requirements because of ongoing storm-related impact, Prestige Health Choice will continue to reimburse for:

  • Services furnished after the disaster grace period without prior authorization and without regard to service limitations.
  • Services provided by a current Medicaid-enrolled provider in those instances where the provider and/or member could not comply with policy requirements because of ongoing storm-related impacts.

Providers must have rendered services in good faith to maintain the member’s health and safety. Examples of such instances include:

  • Provider still does not have access to the Internet or phone services as a result of continued power outages, therefore could not request prior authorization timely.
  • The member continues to be displaced and must receive services in a different region of the state or out of state.
  • The member’s assigned PCP or specialist’s office remains closed due to the storm, and urgent care is rendered at another provider’s location without prior authorization.
  • In order to be reimbursed for eligible Prestige Health Choice members for dates of service within this period, providers not already enrolled in Florida Medicaid (out-of-state or in-state) must complete a provisional (temporary) enrollment application. The process for provisional provider enrollment is located at the AHCA Hurricane Michael information page. This process should be completed PRIOR to submitting your claim to the Prestige Health Choice Claims Payment Exception Process.

Provider provisional enrollment

If a Provider and Billing Group DOES NOT Have a Florida Medicaid Number, you MUST FIRST apply for a Florida Medicaid ID.

To Apply for your Florida Medicaid Number:

For Medicaid providers within the State of Florida that are not enrolled with Florida Medicaid, along with out-of-state providers who are providing services to displaced Florida residents, Florida Medicaid is waiving the requirements to submit documentation showing the nature of the treatment, as well as other normally-required information. Until further notice, Florida Medicaid will only require the following:

  • A fully completed claim form containing the provider’s active National Provider Identifier (NPI), along with the provider’s SSN/FEIN (this claim will not be reimbursed by AHCA, it is being used by AHCA as part of their provider provisional enrollment process only after you receive your provisional provider number, you will need to resubmit this claim to Prestige Health Choice for claims processing  and reimbursement).
  • A signed Florida Medicaid Provider Agreement (MPA):
  • A copy of the provider’s professional license.
  • An optional signed Electronic Funds Transfer (EFT)  Authorization Agreement (PDF), if providers choose to receive payment electronically.

After obtaining your Provider and/or group Florida Medicaid ID number from the state of Florida, you will then need to complete the Prestige Health Choice provider registration form (PDF).  This registration form will assist Prestige Health Choice in setting you up in the Prestige Health Choice claims payment system so that we can process your claims appropriately.

Once you have completed this form, please fax the completed form to 1-844-518-2552 or email to PHCPNORequests@prestigehealthchoice.com. In addition to this form, Prestige Health Choice will also need the following documentation:

  • A complete and signed W9.
  • A copy of your AHCA letter indicating your Florida Medicaid provider and group Medicaid IDs.
  • A copy of 1 claim for provider setup purposes (this claim will not be forwarded to claims).

Prestige Health Choice claims payment exception process

Prestige Health Choice will reimburse for a medically necessary service that was provided to an impacted Prestige Health Choice member DURING the designated disaster grace periods (10/7/2018 through 10/21/2018 or 10/22/2018 through 11/9/2018) for the following:

    • The service(s) would have required a prior authorization.
    • The service(s) was rendered by a non-participating provider.
    • The service(s) exceeded normal policy limits for the service(s).

During this designated disaster grace period, providers should follow the usual Prestige Health Choice claims submission process.

For medically necessary service(s) that were provided to an impacted Prestige Health Choice member OUTSIDE of the designated disaster grace periods to be considered for reimbursement by the Plan, the provider MUST submit the following information:

      • A completed Prestige Health Choice Claims Exception Form (PDF).
      • A contact name, telephone number, and email address for the provider/provider office.
      • A copy of the Agency’s letter reflecting your Medicaid provisional enrollment number.
      • A paper provider claim to ensure proper processing.

Please note that for this claims payment exceptions process, Prestige Health Choice’s process will include the waiver of non-applicable provider credentialing requirements.

Please provide all documentation in hard copy. All information should be sent to:

Prestige Health Choice
Claims Exception Process-Hurricane Michael
11631 Kew Gardens Avenue, Suite 200
Palm Beach Gardens, FL  33410

For any questions regarding the claims payment exception process for Hurricane Michael, please call 1-888-599-1476 or email your question to HurricaneClaimExceptionProcess@prestigehealthchoice.com.