Product A

Florida Medicaid Overview

Company A offers claims processing support for Florida Medicaid. You can process Florida Medicaid claims
for multiple provider types with dates of service on and after 1/1/2022 and claims for Professional and
Suppliers provider types with dates of service on and after 1/1/2021. Florida Medicaid reimburses qualified
medical expenses based on eligibility criteria determined by the Florida Agency for Health Care
Administration (AHCA).

Product A supports a number of Florida Medicaid provider types, which we describe below.

Ambulance
Ambulatory Surgery Center (ASC)
End-Stage Renal Disease (ESRD)
Home Health
Hospice
Inpatient
Nursing Facility (NF)
Outpatient
Professional
Suppliers

Ambulance
The ambulance provider type for Florida Medicaid applies to ground and air transportation services and
medical supplies rendered in Florida. Florida Medicaid issues a list of covered allowable ground and air
transportation services. Additionally, reimbursement for medical services is related to the allowable services
identified in the Provider Specific File. Pricing includes reimbursing the applicable rate based on the reported
HCPCS code.

Below is how we support Florida Medicaid ambulance claims.

Pricer
You can set up the following pricer in a Burgess Source configuration to price applicable claims:

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
1
 MD07FL—Florida Medicaid Ambulance Pricer (under GMD07—Medicaid Ambulance Pricer Group)
Claim Level: Line
Description: Determines payment for ambulance services based on Florida Medicaid fee schedule
rates.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.

Edits
To see the available edits for Florida Medicaid ambulance, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select Ambulance.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input
Below we detail the claim inputs specific to Florida Medicaid ambulance claims processing (which may also
apply to other provider types and/or Medicaid states) that are in addition to the existing ambulance claim
input support in Product A.

Auto Interface Accepted

UI Field
Property/Field Location Description Input
Name
Name Values/Format

EMG Emg Line This indicates whether or not the service Alphanumeric
(Text field) was an emergency. inputs:

Y = Yes
N = No

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: For 2 characters
(Drop-down) automated claims processing, this property
is also returned in the envelope in the
automated claim response.)

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
2
Ambulatory Surgery Center (ASC)
The ambulatory surgery center (ASC) provider type for Florida Medicaid applies to freestanding facilities that
operate exclusively for the purpose of furnishing outpatient surgical services. Florida Medicaid issues a list of
outpatient surgical services that are covered in the ASC setting along with associated rates. The ASC fee
schedule payment covers all services provided in the ASC in accordance with Medicare ASC guidelines with
Florida Medicaid-specific exceptions and additions for specific procedures. Additionally, Florida Medicaid
reimburses for ASC services using the Enhanced Ambulatory Patient Grouping (EAPG) reimbursement
methodology. Florida Medicaid ASC follows outpatient sets of National Correct Coding Initiatives (NCCIs)
and Medicaid frequency editing.

Below is how we support Florida Medicaid ASC claims.

Note: Currently, pricers and edits for Florida Medicaid ASC are only available if you also license 3M™
GPCS.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD05FL—Florida Medicaid ASC Pricer (under MD05—Medicaid ASC Pricer Group)

Claim Level: Line
Description: Determines payment for ASC services based on Florida Medicaid fee schedule rates.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.
Provider Matrix Rate Percent Of Fee Schedule—Select and use a specific provider fee schedule
for reimbursement. If the provider isn't found, services are reimbursed at the default percent of fee
schedule for the pricer. This parameter is off by default.
Use Medicaid ID—Reimburse rates based on the reported state Medicaid provider ID instead of
the billing NPI. This parameter is off by default.
Custom Out of State Rates—Price servers rendered using custom out-of-state rates. This
parameter is off by default.
Fee Schedule Name—By default, reimbursement rates are provided by 3M for GPCS pricing.
Optionally select your own 3M fee schedule from this list to use your rates for GPCS pricing.

Edits
To see the available edits for Florida Medicaid ASC, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
3
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select 3M.
b. In the By Provider Types field, select Ambulatory Surgery Center.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input/Output
Below we detail the claim inputs and outputs specific to Florida Medicaid ASC claims processing (which may
also apply to other provider types and/or Medicaid states). These are in addition to the existing ASC claim
input/output support in Product A, though we've repeated some here because they are required for this
provider type.

Input

Accepted
UI Field Auto Interface
Location Description Input
Name Property/Field Name
Values/Format

Beneficiary BeneficiaryZip Header The ZIP code of the patient's Alphanumeric;

ZIP mailing address. 10 characters
(Text field)

Billing NPI BillingNpi Header The NPI of the billing provider. Numeric;
(Text field) 10 digits

Medicaid StateMedicaidProviderID Header The unique provider identifier Alphanumeric;

Prov. ID assigned by the state Medicaid 15 characters
(Text field) plan that may be used for provider
validation and pricing logic if a valid
NPI or CCN is not provided.
(Note: This is required on the claim
when a custom fee schedule by
Medicaid Provider ID is used and
the Use Medicaid ID pricer
parameter is enabled in the
configuration.)

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
4
 Accepted
UI Field Auto Interface
Location Description Input
Name Property/Field Name
Values/Format

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: 2 characters
(Drop- For automated claims processing,
down) this property is also returned in the
envelope in the automated claim
response.)

Patient PatientDischargeStatus Header The code that reflects the patient’s Numeric;
Status discharge status or disposition at 2 digits
(Text field) the end of service for the billing
period.

Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable Product
A to return pricer-related outputs in the claims processing results when the Florida Medicaid ASC Pricer
(MD05FL) is used to price the claim. These outputs can be viewed under the EditData array in the line
PriceOutput section in the automated claim response and by clicking the pricer ID that returns in the
processing results of manually processed claims.

The applicable outputs and their details can be found in the 3M GPCS Response Details data dictionary,
specifically:

1. Navigate to the EAPG Properties tab.

2. In the States Impacted column (A), click the filter drop-down arrow.
3. In the search field, enter Florida and click OK.
4. In the same column, click the filter drop-down arrow again.
5. Check both All filter options and click OK.

End-Stage Renal Disease (ESRD)

The end-stage renal disease (ESRD) provider type for Florida Medicaid applies to hospital-based and
freestanding facilities that furnish dialysis services. Florida Medicaid reimburses all facilities under a
composite rate for dialysis services. The all-inclusive rate cover services such as non-physician services,
supplies, diagnostic testing, and drugs related to dialysis. Pricing also covers erythropoietin (EPO) services,
when applicable.

Below is how we support Florida Medicaid ESRD claims.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and Trademark
Office. CPT copyright 2021 American Medical Association. All rights reserved.
5
Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD11FL—Florida Medicaid End Stage Renal Disease (ESRD) Pricer (under GMD11—Medicaid End Stage
Renal Disease (ESRD) Pricer Group
Claim Level: Line
Description: Determines payment for end-stage renal disease services based on Florida Medicaid
composite rates and separately billable items and services for hospital-based providers and renal
dialysis facilities.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.

Edits
To see the available edits for Florida Medicaid ESRD, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select End-Stage Renal Disease.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input/Output
Below we detail the claim input and output specific to Florida Medicaid ESRD claims processing (which may
also apply to other provider types and/or Medicaid states) that are in addition to the existing inpatient claim
input/output support in Product A.

Input

Auto Interface Accepted

UI Field
Property/Field Location Description Input
Name
Name Values/Format

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: For 2 characters
(Drop-down) automated claims processing, this property
is also returned in the envelope in the
automated claim response.)

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
6
Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable Product
A to return the following line-level pricer-related output in the claims processing results when the Florida
End Stage Renal Disease (ESRD) Pricer (MD11FL) is used to price the claim. This output can be viewed
under the EditData array in the line PriceOutput section in the automated claim response and by clicking
the pricer ID that returns in the processing results of manually processed claims.

Data Type
Display Name Symbolic Name Description
and Size

FL Composite FLCompositeFee This indicates which composite fee was Numeric;

Fee used for pricing. (10, 2)

Home Health
The home health provider type for Florida Medicaid applies to an agency or organization enrolled in Florida
Medicaid for the purpose of furnishing home health services. The Florida Medicaid home health fee schedule
covers nursing, home health aide, and therapy services, as well as certain medical supplies, equipment, and
appliances provided at the patient’s place of residence. Home health services are paid at Florida Medicaid-
published rates based on the billed HCPCS/CPT® code. Florida Medicaid home health also follows
professional sets of National Correct Coding Initiatives (NCCIs).

Below is how we support Florida Medicaid home health claims.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD004FL—Florida Medicaid Home Health Pricer (under GMD04—Medicaid Home Health Fee Schedule
Pricer Group)
Claim Level: Line
Description: Determines payment for home health services based on Florida Medicaid fee schedule
rates.
Parameter: Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.

Edits
To see the available edits for Florida Medicaid home health, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
7
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select HH Services under Plan of Care.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input
Below we detail the claim input specific to Florida Medicaid home health claims processing (which may also
apply to other provider types and/or Medicaid states) that is in addition to the existing home health claim
input support in Product A.

Auto Interface Accepted

UI Field
Property/Field Location Description Input
Name
Name Values/Format

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: For 2 characters
(Drop-down) automated claims processing, this property
is also returned in the envelope in the
automated claim response.)

Hospice
The hospice provider type for Florida Medicaid covers services provided to terminally ill patients including
varieties of respite care to support families and caregivers. Palliative and supportive care may be provided in
the patient’s home, a nursing care or institution, and/or a freestanding hospice provider. Hospice services may
be billed under revenue codes determined by the patient’s level of care; reimbursement under one of these
revenue codes include durable medical equipment, medication, and any other healthcare service provided
relating to the patient’s terminal illness. Florida Medicaid also reimburses patients based on provider-specific
per diem rates for limited bed hold and therapeutic leave days.

Below is how we support Florida Medicaid hospice claims.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD10FL—Florida Medicaid Hospice Pricer (under GMD10—Medicaid Hospice Pricer Group)

Claim Level: Line
Description: Determines payment for hospice services based on Florida Medicaid fee schedule rates.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
8
 Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.
Provider Matrix Rate Percent Of Fee Schedule—Select a provider-specific fee schedule for the
percent of fee rate type.

Edits
To see the available edits for Florida Medicaid hospice, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select Hospice.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input
Below we detail the claim input specific to Florida Medicaid hospice claims processing (which may also
apply to other provider types and/or Medicaid states) that is in addition to the existing hospice claim input
support in Product A.

Input

Auto Interface Accepted

UI Field
Property/Field Location Description Input
Name
Name Values/Format

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: For 2 characters
(Drop-down) automated claims processing, this property
is also returned in the envelope in the
automated claim response.)

Inpatient
The inpatient provider type for Florida Medicaid applies to acute care hospitals providing inpatient hospital
services and interim services. In general, every complete inpatient stay is assigned to a single All Patient
Refined Diagnosis-Related Group (APR-DRG) using an algorithm that takes into account the patient’s
diagnoses, age, procedures performed, and discharge status. Each APR-DRG has an assigned relative
weight that reflects the typical hospital resources needed to care for a patient in that APR-DRG, relative to the
hospital resources needed to take care of the average patient. The relative weight may be further refined by a

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
9
high Medicaid volume hold-harmless adjustor, a service adjustor, or an age adjustor. Florida Medicaid
inpatient prospective payment system pricing policies include APR-DRG payments, cost outlier payments,
and per diem payments for interim services and transfers.

Below is how we support Florida Medicaid inpatient claims.

Note: Currently, pricers and edits for Florida Medicaid inpatient are only available if you also license
3M™ GPCS.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD01FL—Florida Medicaid Inpatient Pricer (under GMD01—Medicaid Inpatient Pricer Group)

Claim Level: Header
Description: Determines APR-DRG grouping according to the Florida Medicaid guidelines via the 3M
GPCS software. Pricing is based on Florida Medicaid fee schedules, also provided by 3M.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Provider Matrix Rate Percent Of Fee Schedule—Select and use a specific provider fee schedule
for reimbursement. If the provider isn't found, services are reimbursed at the default percent of fee
schedule for the pricer. This parameter is off by default.
Lesser of Total Charges vs. Claim Total—Pay the lesser of the billed total charges or the
calculated allowance. This parameter is off by default.
Use Medicaid ID—Reimburse rates based on the reported state Medicaid provider ID instead of
the billing NPI. This parameter is off by default.
Custom Out of State Rates—Price servers rendered using custom out-of-state rates. This
parameter is off by default.
Fee Schedule Name—By default, reimbursement rates are provided by 3M for GPCS pricing.
Optionally select your own 3M fee schedule from this list to use your rates for GPCS pricing.

Edits
To see the available edits for Florida Medicaid inpatient, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select 3M.
b. In the By Provider Types field, select Acute Inpatient Hospital.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
10
Claim Input/Output
Below we detail the claim inputs and outputs specific to Florida Medicaid inpatient claims processing (which
may also apply to other provider types and/or Medicaid states). These are in addition to the existing inpatient
claim input/output support in Product A, though we've repeated some here because they are required for
this provider type.

Input

Accepted
UI Field Auto Interface
Location Description Input
Name Property/Field Name
Values/Format

Beneficiary BeneficiaryZip Header The ZIP code of the patient's Alphanumeric;

ZIP mailing address. 10 characters
(Text field)

Billing NPI BillingNpi Header The NPI of the billing provider. Numeric;
(Text field) 10 digits

Medicaid StateMedicaidProviderID Header The unique provider identifier Alphanumeric;

Prov. ID assigned by the state Medicaid 15 characters
(Text field) plan that may be used for provider
validation and pricing logic if a
valid NPI or CCN is not provided.
(Note: This is required on the
claim when a custom fee schedule
by Medicaid Provider ID is used
and the Use Medicaid ID pricer
parameter is enabled in the
configuration.)

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. 2 characters
(Drop-down) (Note: For automated claims
processing, this property is also
returned in the envelope in the
automated claim response.)

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
11
 Accepted
UI Field Auto Interface
Location Description Input
Name Property/Field Name
Values/Format

Patient PatientDischargeStatus Header The code that reflects the Numeric;

Status patient’s discharge status or 2 digits
(Text field) disposition at the end of service
for the billing period.

Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable Product
A to return pricer-related outputs in the claims processing results when the Florida Medicaid Inpatient Pricer
(MD01FL) is used to price the claim. These outputs can be viewed under the EditData array in the line
PriceOutput section in the automated claim response and by clicking the pricer ID that returns in the
processing results of manually processed claims.

The applicable outputs and their details can be found in the 3M GPCS Response Details data dictionary,
specifically:

1. Navigate to the APR-DRG Properties tab.

2. In the States Impacted column (A), click the filter drop-down arrow.
3. In the search field, enter Florida and click OK.
4. In the same column, click the filter drop-down arrow again.
5. Check both All filter options and click OK.

Nursing Facility (NF)

The nursing facility provider type for Florida Medicaid applies to nursing facilities that provide care for the
chronically ill and those recuperating from illness who need 24-hour nursing care but not hospitalization.
Nursing services such as administration of medication, feeding, and routine testing are covered in the facility-
specific per diem rate determined by Florida Medicaid. This rate is based upon the provider rate letter and
covers nutritional and dietary services, medical supplies, and room and board. Florida Medicaid also
reimburses patients based on provider-specific per diem rates for limited therapeutic leave days, hospice
care, and bed hold. Additionally, Florida Medicaid facilities that serve recipients who are designated as
medically fragile also receive a separate per diem reimbursement.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD06FL—Florida Medicaid NF Pricer (under GMD06—Medicaid SNF Pricer Group, under the Skilled
Nursing - Part A provider type and Skilled Nursing - Part B provider type)

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
12
 Claim Level: Line
Description: Determines reimbursement for participating providers according to the Florida Medicaid
guidelines via established per diem rates. Pricing is based on the number of covered days per revenue
code and the per diem rate assigned to each provider.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.

Edits
To see the available edits for Florida Medicaid nursing facility, log in to Product A and follow these
steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select Skilled Nursing - Part A and Skilled Nursing - Part B.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input/Output
Below we detail the claim inputs and outputs specific to Florida Medicaid nursing facility claims processing
(which may also apply to other provider types and/or Medicaid states) that are in addition to the existing
nursing facility claim input/output support in Product A.

Input

Auto Interface Accepted

UI Field Name Property/Field Location Description Input
Name Values/Format

Contract-Code Type, ContractType Header This is used for form locator Alphanumeric;
Code, Amount overflow, specifically to report a 2 characters
(Text field) code list type or qualifier for the
reported data element.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
13
 Auto Interface Accepted
UI Field Name Property/Field Location Description Input
Name Values/Format

Contract-Code Type, ContractCode Header This is used for form locator Alphanumeric;
Code, Amount overflow, specifically to report a 10 characters
(Text field) code such as level of care,
rendering taxonomy, or other
data element as applicable.

Contract-Code Type, ContractAmount Header This is used for form locator Alphanumeric;
Code, Amount overflow, specifically to report a 12 characters
(Text field) corresponding amount or value
for the reported data element.

Medicaid State MedicaidState Header The state to determine Alphanumeric;

(Drop-down) appropriate Medicaid editing 2 characters
and pricing. (Note: For
automated claims processing,
this property is also returned in
the envelope in the automated
claim response.)

Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable
Product A to return the following line-level pricer-related output in the claims processing results when the
Florida Medicaid SNF Pricer (MD06FL) is used to price the claim. This output can be viewed under the
EditData array in the line PriceOutput section in the automated claim response and by clicking the pricer
ID that returns in the processing results of manually processed claims.

Data Type
Display Name Symbolic Name Description
and Size

Per-Diem Rate PerDiemRate The provider's per diem rate. Numeric;

(10, 2)

Outpatient
The outpatient hospital provider type for Florida Medicaid applies to outpatient services rendered in a hospital
facility. The Florida Medicaid Enhanced Ambulatory Patient Group (EAPG) reimbursement formula calculates
outpatient prospective payment for ASC and hospital outpatient Medicaid fee-for-service (FFS) claims. The
Florida Medicaid EAPGs reimbursement associates an EAPG with each service on a claim; each EAPG

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
14
carries its own relative weight that is the basis for payment. Reimbursement parameters defined by the
agency, such as discounting, consolidation, and packaging, may result in adjustment of the weights to obtain
a final weight for each line item on the visit.

Below is how we support Florida Medicaid outpatient claims.

Note: Currently, pricers and edits for Florida Medicaid outpatient are only available if you also license
3M™ GPCS.

Pricers
You can set up the following pricer in a Burgess Source configuration to price applicable claims:

MD02FL—Florida Medicaid Outpatient Fee Schedule Pricer (under GMD02—Medicaid Outpatient Fee
Schedule Pricer Group)
Claim Level: Line
Description: Determines EAPG grouping according to the Florida Medicaid guidelines via the 3M
GPCS software. Pricing is based on Florida Medicaid fee schedules, also provided by 3M.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Provider Matrix Rate Percent Of Fee Schedule—Select and use a specific provider fee schedule
for reimbursement. If the provider isn't found, services are reimbursed at the default percent of fee
schedule for the pricer. This parameter is off by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is off by default.
Use Medicaid ID—Reimburse rates based on the reported state Medicaid provider ID instead of the
billing NPI. This parameter is off by default.
Custom Out of State Rates—Price servers rendered using custom out-of-state rates. This
parameter is off by default.
Fee Schedule Name—By default, reimbursement rates are provided by 3M for GPCS pricing.
Optionally select your own 3M fee schedule from this list to use your rates for GPCS pricing.

Edits
To see the available edits for Florida Medicaid outpatient, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select Hospital Outpatient Department.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
15
Claim Input/Output
Below we detail the claim inputs and outputs specific to Florida Medicaid outpatient claims processing
(which may also apply to other provider types and/or Medicaid states). These are in addition to the existing
outpatient claim input/output support in Product A, though we've repeated some here because they are
required for this provider type.

Input

Accepted
UI Field Auto Interface
Location Description Input
Name Property/Field Name
Values/Format

Beneficiary BeneficiaryZip Header The ZIP code of the patient's Alphanumeric;

ZIP mailing address. 10 characters
(Text field)

Billing NPI BillingNpi Header The NPI of the billing provider. Numeric;
(Text field) 10 digits

Medicaid StateMedicaidProviderID Header The unique provider identifier Alphanumeric;

Prov. ID assigned by the state Medicaid 15 characters
(Text field) plan that may be used for provider
validation and pricing logic if a
valid NPI or CCN is not provided.
(Note: This is required on the
claim when a custom fee
schedule by Medicaid Provider ID
is used and the Use Medicaid ID
pricer parameter is enabled in the
configuration.)

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. 2 characters
(Drop-down) (Note: For automated claims
processing, this property is also
returned in the envelope in the
automated claim response.)

Patient PatientDischargeStatus Header The code that reflects the Numeric;

Status patient’s discharge status or 2 digits
(Text field) disposition at the end of service
for the billing period.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
16
Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable Product
A to return pricer-related outputs in the claims processing results when the Florida Medicaid Outpatient
Fee Schedule Pricer (MD02FL) is used to price the claim. These outputs can be viewed under the EditData
array in the line PriceOutput section in the automated claim response and by clicking the pricer ID that
returns in the processing results of manually processed claims.

The applicable outputs and their details can be found in the 3M GPCS Response Details data dictionary,
specifically:

1. Navigate to the EAPG Properties tab.

2. In the States Impacted column (A), click the filter drop-down arrow.
3. In the search field, enter Florida and click OK.
4. In the same column, click the filter drop-down arrow again.
5. Check both All filter options and click OK.

Professional
The professional provider type for Florida Medicaid applies to services furnished by practitioners in a variety of
settings, including physicians’ offices, hospitals, ambulatory surgery centers, skilled nursing facilities and
other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and patients’
homes. Professional medical services can be rendered by physicians and non-physicians (e.g., physician
assistants and nurse practitioners) and include office visits, evaluation and management services, surgical
procedures, and a broad range of other diagnostic and therapeutic services. Services are reimbursed at
Florida Medicaid fee-for-service (FFS) rates with specific pricing based on HCPCS/CPT® code, provider and
specialty type codes, place of service code, modifier combinations, and anesthesia pricing for CPT codes in
the 00100-01999 range based on minutes billed on the claim line. Florida Medicaid also applies National
Correct Coding Initiatives (NCCIs) procedure-to-procedure (PTP) editing and medically unlikely editing
(MUE), Multiple Procedure Payment Reduction (MPPR) adjustments for surgery, pediatric adjustments, and
modifier editing.

Below is how we support Florida Medicaid professional claims.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD09FL—Florida Medicaid Professional Pricer (under GMD09—Medicaid Professional Pricer Group)

Claim Level: Line
Description: Determines payment for professional services based on Florida Medicaid fee schedule
rates.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
17
 Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated allowance.
This parameter is off by default.

Edits
To see the available edits for Florida Medicaid professional, log in to Product A and follow these steps:

1. Navigate to Design > Edit Libraries.

2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid and/or Medicare (to include CMS-based edits for
Florida Medicaid professional).
b. In the By Provider Types field, select Professional.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input/Output
Below we detail the claim inputs and outputs specific to Florida Medicaid professional claims processing
(which may also apply to other provider types and/or Medicaid states) that are in addition to the existing
professional claim input/output support in Product A.

Input

Auto Interface Accepted

UI Field
Property/Field Location Description Input
Name
Name Values/Format

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: For 2 characters
(Drop-down) automated claims processing, this property
is also returned in the envelope in the
automated claim response.)

Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable
Product A to return the following line-level pricer-related outputs in the claims processing results when the
Florida Medicaid Professional Pricer (MD09FL) is used to price the claim. These outputs can be viewed
under the EditData array in the line PriceOutput section in the automated claim response and by clicking
the pricer ID that returns in the processing results of manually processed claims.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
18
 Data
Display Type
Symbolic Name Description
Name and
Size

FL Fee FLFeeScheduleIndicator This identifies the Florida Medicaid Durable Medical Numeric;
Schedule Equipment (DME) and medical supply services fee 1 digit
Indicator schedule indicator.

FL Provider FLProviderType This identifies the Florida Medicaid provider. Numeric;

Type 2 digits

FL Specialty FLSpecialtyCode This identifies the Florida Medicaid specialty code. Numeric;
Code 3 digits

Suppliers
The suppliers provider type for Florida Medicaid applies to Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) providers, as well as orthopedic specialists. Florida Medicaid suppliers
are reimbursed based on the Florida Medicaid Medical Suppliers/Orthotists/Prosthetists/DME Dealers Fee
Schedule rates at the HCPCS/CPT® code and/or modifier level. Florida Medicaid suppliers follow National
Correct Coding Initiatives (NCCIs) procedure-to-procedure (PTP) and medically unlikely editing (MUE).

Below is how we support Florida Medicaid suppliers claims.

Pricer
You can set up the following pricer in a Product A configuration to price applicable claims:

MD08FL—Florida Medicaid DME Pricer (under GMD08 DME Pricer Group)

Claim Level: Line
Description: Determines reimbursement for DME billed by suppliers using the Florida Medicaid DME
fee schedule.
Parameters:
Percent of Fee Schedule—Price at a percentage of the fee schedule rate. This parameter is set to
100% by default.
Lesser of Charges vs. Allowance—Pay the lesser of the billed charge or the calculated
allowance. This parameter is on by default.
Pay Up to Maximum Units—Pay up to the maximum allowed units when the limit for the
procedures as defined by the fee schedule is exceeded.

Edits
To see the available edits for Florida Medicaid suppliers, log in to Product A and follow these steps:

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
19
1. Navigate to Design > Edit Libraries.
2. In the Edit Libraries view, click the More Options list and select Advanced Filter.
3. When the Advanced Edit Filter appears, enter the following:
a. In the By Edit Sources field, select Medicaid.
b. In the By Provider Types field, select Suppliers.
c. In the By Medicaid States field, select Florida.
4. Click Filter to see the list of applicable edits.

Claim Input/Output
Below we detail the claim input and outputs specific to Florida Medicaid suppliers claims processing (which
may also apply to other provider types and/or Medicaid states) that are in addition to the existing suppliers
claim input/output support in Product A.

Input

Auto Interface Accepted

UI Field
Property/Field Location Description Input
Name
Name Values/Format

Medicaid MedicaidState Header The state to determine appropriate Alphanumeric;

State Medicaid editing and pricing. (Note: For 2 characters
(Drop-down) automated claims processing, this property
is also returned in the envelope in the
automated claim response.)

Output
In Product A under Admin > Set up Pricer Settings > Pricer Info Options , you can optionally enable Product
A to return the following line-level pricer-related outputs in the claims processing results when the Florida
Medicaid DME Pricer (MD08FL) is used to price the claim. These outputs can be viewed under the EditData
array in the line PriceOutput section in the automated claim response and by clicking the pricer ID that
returns in the processing results of manually processed claims.

Data
Display Type
Symbolic Name Description
Name and
Size

FL Fee FLFeeScheduleIndicator This identifies the Florida Medicaid Durable Medical Numeric;
Schedule Equipment (DME) and medical supply services fee 1 digit
Indicator schedule indicator.

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
20
 Data Type and
Display Name Symbolic Name Description
Size

FL Provider Type FLProviderType This identifies the Florida Medicaid provider. Numeric;
2 digits

FL Specialty FLSpecialtyCode This identifies the Florida Medicaid specialty Numeric;

Code code. 3 digits

Company A, Sensitive, and Proprietary. © 2022 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2021 American Medical Association. All rights reserved.
21