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Florida Providers NPI Data Changes Tip Sheet

Date: 01/19/24

Fort Lauderdale, Florida

Florida is changing how it accepts electronic claims/encounters: Billing provider information must match exactly the National Provider Identifier (NPI) that AHCA has on file, or the encounters will be denied.

This is set to take effect January 25, 2024.

Sunshine Health will not be able to alter provider-submitted taxonomy or address data on claims received; paid claims are subsequently submitted to Florida Medicaid in the form of encounters. Providers will be required to correct their billing information on all submitted claims to allow the health plan to resubmit the encounter data.

That means provider billing information used in the CMS-1500 paper claim form, UB-04 paper claim form and the X12 837 electronic claim submission must match exactly the billing provider’s service location address listed on the Florida Medicaid Provider Master List (PML).

Here are two ways providers can confirm their data and address on file:

  • Log into the Florida Medicaid Secure Web Portal, navigate to Demographic Maintenance and select the NPI link.
  • Go to the Florida Medical Web Portal page and scroll down to Provider Information Reports to find the most current Provider Master List (PML) spreadsheet. Open the Excel file and check the provider address under Column G.

The PML Tip Sheet (PDF) offers guidance on navigating the PML.

Learn More About the NPI Initiative

The NPI Frequently Asked Questions (PDF) explains the changes in Florida.

What changes are being made?

The following updates will be implemented with this initiative.

NPI Mapping Logic (Effective January 25, 2024):

  • The NPI Mapping Logic will only consider matching the NPI to enrolled Medicaid Provider IDs based on Contract Date spans (Effective/End Dates) that were active during the submitted Date of Service.
  • When multiple enrolled Medicaid Provider IDs potentially match all of the submitted data, the NPI Mapping Logic selects one as the default. The new NPI Matching Logic defaults to the Medicaid Provider ID with the most recent Contract Effective Date from multiple Medicaid Provider IDs, which have been narrowed down at that point in the logic.

Taxonomy Master List (TML):

  • The Florida Medicaid Web Portal allows providers to view all valid taxonomies for the specialty/specialties they have on file. Scroll down to Taxonomy Master List (TML).
  • The TML is replacing the Taxonomy Guide and is available for downloading in a similar layout as the PML/PPL.
  • The TML also includes the Provider Type number and Provider Specialty number.

The TML Tip Sheet (PDF) offers guidance on navigating the TML.

Taxonomy Matching Logic

  1. The submitted taxonomy on a CMS-1500 claim form is exclusively used for NPI/PID matching logic.
  2. The taxonomy is used to create a unique match to PID. For example, when a submitted NPI has multiple PIDs associated with it, then the taxonomy is required. The submitted taxonomy is compared to the Taxonomy Master List (TML). If the submitted taxonomy is not found on the TML, it will result in an error. When it is found on the TML, the associated provider type and specialty is ascertained. If no PID enrolled under the submitted NPI with that ascertained provider type is found, it will result in an error. If one unique PID enrolled under the submitted NPI with the ascertained provider type is found, there will be a unique match. If multiple PIDs under the submitted NPI and ascertained provider type are found, then the submitted address will be used to find a match.
  3. The submitted taxonomy can be ANY taxonomy found to be associated with the provider type and specialty of the desired PID listed on the TML.
  4. For encounters with DOS 3/1/22 or later, taxonomy submissions are not limited to the taxonomies displayed in the PML. The PML reflects the enrolled taxonomy on the provider file.
  5. In some cases, past enrollments allowed taxonomies to be enrolled that may not be correctly associated with the provider type of the enrolled PID. In those cases, submission of the incorrect taxonomy as posted in the PML would be invalid. Submitters should consult the TML posted on the public portal to find a correct taxonomy to submit.

Questions?

If you have any questions, please call Sunshine Health Provider Services at 1-844-477-8313 or visit the Secure Provider Portal. Our Provider Engagement staff are also here to help answer questions. Visit the Find Your Administrator tool to confirm the individual supporting your specialty and region. We encourage you stay up to date on Sunshine Health provider notices by reviewing and bookmarking Provider News.

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