Item C16
MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: October 18-19. 2000
Bulk Item: Yes X No
Division: Public Safety
Department: Public Safety
AGENDA ITEM WORDING: Approval for Mayor to execute Florida Medicaid ProviderlBilling Agent
Agreement in regards to ambulance billing services
ITEM BACKGROUND: At the August 16,2000 meeting, the Board approved an agreement between
Monroe County and Advanced Data Processing, Inc. for ambulance billing and related professional
services. The attached Florida Medicaid ProviderlBilling Agent Agreement is required to authorize
Advanced Data Processing, Inc., as billing agent, to submit claims for reimbursement by Florida Medicaid
on behalf of Monroe County for ambulance services.
PREVIOUS RELEVANT BOCC ACTION: See above
STAFF RECOMMENDATION: Approval
TOTAL COST: 0.00
COST TO COUNTY: 0.00
REVENUE PRODUCING: Yes
BUDGETED: Yes
No
No
N/A
APPROVED BY: County Attorney YES
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION: Included: X To Follow: _ Not Required:
DISPOSITION:
Agenda Item #: 1- C/(p
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This form must be completed by any applicant who will be using a billing agent
to submit claims for reimbursement by Florida Medicaid.
Please read Notice to Providers and Billini! Ai!ents on the back of this pai!e.
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I, \ "( _ 0 (\ fa e U0u f)' authorize ~ C\03. \10 C - 00
(Provid<< D&mCIpnl'iidcr DUIIlbcc) (Billin& apdJ BilIiai .,. provWiar DWDbcr)
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to submit claims to and follow up with Medicaid and/or the Medicaid Fiscal Agent on my behalf
I understand that all payments and payment infonnation are in my name and that this agreement
does not exempt me from responsibility for claims filed on my behalf or from established claim
filing policies. I further understand that the billing agent must be held to the same requirements of
confidentiality and access to records that I am. as reflected in my agreement with Medicaid. I will
inunediately notify the Medicaid fiscal agent of any change in this authorization.
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Provider Name Title
\; (pLEASE PRINT LEOlBLY)
Provider Signature
Date
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If this fonn is being completed ~ you have been notified of your Florida Medicaid provider
number(s), please supply the provider number(s) you have been assigned to your practice or
facility. Otherwise, you may leave this section blank.
Florida Medicaid Provider Numbers 0 61...J 3 6 \- 00.
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Return this completed agreement with your application or, after provider number is
a8Si~ned, lend it directly to:
Medicaid Fiscal Alent
Provider Enrollment
P. O. Box 7070
Tallahassee, FL 32314-7070
AHCA Form 2200-0003 (November 1998)
". l ZANN9f fJECATION Pap 11
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The following requirements apply to all billing agents:
. You must,be enrolled in the Medicaid program as a billing agent with an active provider
number to bill claims on behalf of an enrolled Medicaid provider.
. Claims must be paid in the name of the provider or provider group that renders the services,
not in the name of the billing agent.
. Payment'for billing services must be made based 'upon an administrative fee per claim. Federal
regulation (42 CFR 447.10, Subpart A) prohibits billing agents from charging for their
services based upon a percentage of the total dollar value of claims billed.
. If a claim is rejected as inaccurately filed, it cannot be resubmitted unless there has been a
change made to the claim form or electronic submission itself
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ARCA Form 2200-0003 (November 1998)
APPLICATION Page 18
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