Florida Medicaid Billing & Managed Care
Florida Medicaid Billing Requirements
Navigate Florida Medicaid billing with clearer guidance around managed care plans, provider enrollment, HCPCS codes, modifiers, telehealth, EPSDT, denials, and payer-specific claim requirements.
- Florida Medicaid MCO guidance
- Provider enrollment & credentialing
- H-codes, T-codes & modifiers
- Telehealth billing requirements
- EPSDT & pediatric billing
- Claims, denials & timely filing
Florida Medicaid Billing Support
Florida Medicaid Is Not One Single Set of Rules
Florida Medicaid billing depends on whether the patient is covered through fee-for-service Medicaid or a Statewide Medicaid Managed Care plan.
Requirements can change based on the patient’s plan, product, region, provider type, service, authorization status, place of service, and date of service.
That means a claim that is correct for Florida Medicaid fee-for-service may still require different coding, authorization, telehealth, or submission rules under a Medicaid MCO.
Quest National Services helps Florida practices manage medical billing, coding, claims, denials, payer enrollment, and broader revenue cycle workflows.
Florida Managed Care Landscape
Florida Medicaid MCO Plans, Regions & Coverage
Florida’s Statewide Medicaid Managed Care program uses contracted private health plans. Some operate across all nine Medicaid regions, while others serve selected areas or specific populations.
Florida Community Care
Regions: A–I
All-region footprint, some products can vary by region.
Aetna Better Health
Regions: D, E, I
Regional Florida Medicaid managed care participation.
Humana
Regions: A–I
Humana Medical Plan / Humana Healthy Horizons.
Community Care Plan
Regions: E, F, G, H, I
Regional participation across Central and South Florida.
Simply Healthcare
Regions: A–I
All-region Medicaid managed care footprint.
Molina Healthcare
Region: I
Regional for its regular comprehensive SMMC contract, with separate specialty-program responsibilities.
Sunshine Health
Regions: A–I
All-region footprint with additional specialty populations.
UnitedHealthcare
Regions: B, D, I
Regional Florida Medicaid managed care participation.
Florida Medicaid Regions by County
Region A: Bay, Calhoun, Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, Washington.
Region B: Alachua, Baker, Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, Volusia.
Regions C–I: C covers Pasco and Pinellas; D covers Hardee, Highlands, Hillsborough, Manatee and Polk; E covers Brevard, Orange, Osceola and Seminole; F covers Charlotte, Collier, DeSoto, Glades, Hendry, Lee and Sarasota; G covers Indian River, Martin, Okeechobee, Palm Beach and St. Lucie; H covers Broward; I covers Miami-Dade and Monroe.
Always verify the member’s current MCO and product rather than assuming billing requirements based only on the insurance company’s name.
Provider Enrollment
Florida Medicaid Enrollment & MCO Participation
Florida Medicaid enrollment and participation in a Medicaid MCO network are two separate processes.
Florida Medicaid Enrollment Types
- Fully enrolled: Generally eligible to render and bill applicable FFS and managed care services
- Limited enrolled: Participates in a managed care network but is not ordinarily eligible for FFS billing
- Ordering or referring: Used for practitioners who order, refer, prescribe, certify, or participate without necessarily submitting the payable claim
Medicaid Enrollment Does Not Equal MCO Network Status
After enrolling with Florida Medicaid, providers may still need to separately complete an MCO’s credentialing, contracting, network effective-date, EDI, EFT/ERA, taxonomy, location, and group-affiliation requirements.
A mismatch between Medicaid enrollment information and the plan’s provider file can create preventable denials even when the underlying service is covered.
Learn more about Quest’s credentialing and contracting services.
Florida Medicaid Coding
Florida Medicaid HCPCS Codes & Modifier Requirements
Florida Medicaid primarily uses national CPT and HCPCS codes. The Florida-specific requirement is often the exact combination of code, modifier, units, provider credential, service limits, place of service, and authorization.
Providers should use the AHCA fee schedule or billing-code table effective on the date of service and then apply any additional MCO requirements.
Behavioral Health
Florida Medicaid frequently uses H-codes for behavioral health assessments, evaluations, treatment, and related services.
Examples: H0001, H0031, H2000, H2010 and H2019.
Case Management
Targeted case-management programs may use T-code and modifier combinations based on the population and service.
Examples: T1017-HA, T1017-HK, T1017-TL and T1017-SE.
Early Intervention
Early-intervention services can use T1023, T1024 and T1027 with credential, discipline, team, and service modifiers.
Waiver & Program Billing
Florida continues to use program-specific billing tables, code-modifier combinations, provider restrictions, units, and service limits for waiver and specialty services.
When Are HO, HN & UD Required?
HO and HN are service-specific. They should not automatically be selected simply because a clinician has a particular degree.
Examples include combinations such as H2000-HO, H0031-HO, H0031-HN, H2019-HO, and H2019-HN. The appropriate modifier depends on the exact service, provider credential, taxonomy, authorization, and fee-schedule requirement.
UD is not a universal Florida Medicaid modifier. Do not automatically apply it simply because the payer is Medicaid or because a drug involves 340B. Use it only when the applicable AHCA or MCO policy specifically requires it.
QuestNS provides medical coding solutions to support payer-specific coding workflows.
Virtual Care Billing
How to Bill Telehealth for Florida Medicaid
Telehealth is one of the clearest examples of why Florida Medicaid fee-for-service and managed care claims should not use one universal billing rule.
Florida Medicaid Fee-for-Service
For applicable professional telemedicine claims, Florida’s statewide FFS framework requires:
- Proper Medicaid provider enrollment
- Two-way, real-time audio and video
- Applicable medical-necessity and documentation requirements
- Any otherwise required authorization
- Modifier GT on the professional CMS-1500 claim
Modifier 95 and POS 02/10 are not universal Florida Medicaid FFS requirements.
I have gone back to seeing my patients and no longer have to worry or follow up on the billing part of my practice because QNS has me covered.
Pediatric Medicaid Billing
Florida Medicaid EPSDT & Child Health Check-Up Billing
Florida’s EPSDT preventive program is commonly referred to as Child Health Check-Up (CHCUP).
The program provides preventive screening beginning in infancy and continuing through age 20. Depending on age and applicable policy, visits may include physical, developmental, growth, immunization, vision, hearing, dental, laboratory, anticipatory-guidance, and referral components.
QuestNS also provides specialized pediatric medical billing services.
New Patient Preventive Visits
- 99381: Younger than age 1
- 99382: Ages 1–4
- 99383: Ages 5–11
- 99384: Ages 12–17
- 99385-EP: Ages 18–20 when applicable
Established Patient Preventive Visits
- 99391: Younger than age 1
- 99392: Ages 1–4
- 99393: Ages 5–11
- 99394: Ages 12–17
- 99395-EP: Ages 18–20 when applicable
When Is Modifier EP Required?
Under the current Florida Medicaid FFS practitioner schedule, modifier EP identifies the applicable well-child preventive visit for recipients ages 18 through 20.
That means EP applies to 99385-EP for an eligible new-patient visit and 99395-EP for an eligible established-patient visit.
Do not automatically append EP to every pediatric well visit, vaccine, laboratory test, developmental screening, or sick visit.
Claims & Denial Management
How to Submit Florida Medicaid Claims Correctly
A valid procedure code alone does not guarantee that a Florida Medicaid claim will process correctly.
Provider enrollment, MCO assignment, authorization, modifiers, taxonomy, units, telehealth rules, timely filing, documentation, and plan-specific edits can all affect the claim.
Florida Medicaid Fee-for-Service
- Verify current AHCA coverage policy
- Use the correct effective fee schedule
- Confirm provider eligibility
- Validate CPT/HCPCS and modifiers
- Verify units and service limits
- Confirm authorization requirements
- Apply applicable telehealth rules
- Ensure documentation supports the service
Florida Medicaid Managed Care
- Verify member’s assigned MCO and product
- Confirm provider network effective date
- Check MCO authorization requirements
- Review reimbursement policy
- Review provider manual and EDI guidance
- Confirm telehealth billing rules
- Check corrected-claim procedures
- Verify reconsideration and appeal deadlines
Timely Filing & Medicaid Denials
Managed care claims can have different deadlines for original submissions, corrected claims, reconsiderations, appeals, authorization disputes, and medical-record requests.
A denied Medicaid claim should be reviewed for the actual cause before it is simply corrected or resubmitted.
Common issues include provider enrollment, network effective dates, authorization, taxonomy, modifiers, units, service limits, telehealth requirements, coordination of benefits, and documentation.
QuestNS provides denial management and appeals support designed to identify the issue, determine the appropriate next step, and follow unresolved claims through resolution.
Beyond Medicaid Claims
Florida Medicaid Billing Services for Healthcare Providers
Managing Florida Medicaid across FFS and multiple managed care plans can create significant administrative work for healthcare practices.
Quest National Services supports payer-specific billing workflows designed around the needs of the individual practice.
Claims & Coding
Claim creation, coding support, edits, submission, corrections, and payer follow-up.
Behavioral Health
Support for payer-specific H-codes, T-codes, modifiers, and behavioral health workflows.
Denials & Appeals
Identify denial causes, correct appropriate issues, and manage payer appeals.
Aging A/R
Follow unresolved and aging Medicaid balances through the appropriate next action.
Eligibility & Authorization
Verify coverage and support applicable prior-authorization requirements.
Credentialing
Support Florida Medicaid enrollment and MCO payer credentialing workflows.
Financial Reporting
Improve visibility into claims, denials, A/R, collections, and payer activity.
Revenue Cycle Management
Broader support across eligibility, claims, denials, collections, and reporting.
For broader statewide support, explore our Florida medical billing services.
For complete revenue cycle support, visit our Florida revenue cycle management services.
Customized Around Your Practice
How Much Do Florida Medicaid Billing Services Cost?
There is no single pricing structure that fits every Florida Medicaid practice.
Pricing may vary based on specialty, provider count, claim volume, Medicaid concentration, payer mix, existing A/R, coding complexity, authorization workload, technology, credentialing needs, and overall service scope.
When comparing billing partners, look beyond the percentage alone. Consider who handles claims, denials, appeals, payer follow-up, A/R, reporting, credentialing, eligibility, and the billing work that would otherwise remain with your internal team.
Have questions? We’ve got answers.
Who manages Florida Medicaid?
Florida Medicaid is administered by the Florida Agency for Health Care Administration. Much of the Medicaid population receives services through private health plans participating in the Statewide Medicaid Managed Care program.
What are the major Florida Medicaid managed care plans?
Major plans include Aetna Better Health, Community Care Plan, Florida Community Care, Humana, Molina, Simply Healthcare, Sunshine Health, and UnitedHealthcare Community Plan. Plan availability varies by region and Medicaid product.
Can a provider be enrolled in Florida Medicaid but out-of-network with an MCO?
Yes. Florida Medicaid enrollment and MCO network contracting are separate processes. A provider may be enrolled with Medicaid without being contracted and effective with a particular managed care plan.
Does Florida Medicaid require GT or modifier 95 for telehealth?
For applicable Florida Medicaid fee-for-service professional telemedicine claims, the statewide rule uses modifier GT. Managed care requirements vary, and some plans publish different instructions involving GT, 95, or other claim requirements.
Does Florida Medicaid require POS 02 or POS 10 for telehealth?
POS 02 and POS 10 are not universal requirements under Florida’s statewide Medicaid FFS telemedicine rule. Providers should verify the applicable MCO or service-specific policy before billing.
Does Florida Medicaid still use H-codes and T-codes?
Yes. H-codes and T-codes remain important for services including behavioral health, case management, early intervention, waiver programs, and other Medicaid-specific benefit categories.
When are modifiers HO and HN required?
HO and HN are service-specific modifiers. Providers should use them only when the applicable Florida Medicaid fee schedule or MCO policy requires the modifier for the specific code, service, credential, and provider type.
When is modifier EP required by Florida Medicaid?
Under the current Florida Medicaid FFS practitioner schedule, EP identifies applicable well-child preventive visits for recipients ages 18 through 20, including 99385-EP and 99395-EP. It should not automatically be added to every pediatric preventive service.
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Simplify Medicaid Billing
Take the Complexity Out of Florida Medicaid Billing
Quest National Services helps Florida practices manage Medicaid claims, coding, enrollment, denials, appeals, A/R follow-up, and payer-specific workflows—so your team can spend less time navigating billing requirements and more time focused on patient care.
Explore our Florida Medical Billing Services or Florida Revenue Cycle Management Services.
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