The Agency for Health Care Administration (AHCA) has adjusted the Practitioner payment methodology to include a Pediatric Rate Increase of 7.3% to the Practitioner Fee Schedule for Physicians PT25 (M.D.) and PT26 (D.O), serving recipients ages 0-20 years.
AHCA has included the 7.3% Pediatric Rate Increase as directed in the 2023-24 General Appropriations Act. This increase was implemented December 8, 2023, and the rates are effective October 1, 2023.
To receive the higher rates for fee-for-service (FFS) claims or encounter transactions with Dates of Service on or after October 1, 2023, and submitted prior to December 8, 2023, you will need to adjust the transaction. If the Billed Amount is less than the new max fee, the Billed Amount(s) must be updated. Florida Medicaid pays the lesser of the amount billed or the allowed amount (max fee). Detailed instructions are below for FFS claim and encounter adjustments.
The Practitioner Fee Schedule can be accessed on AHCA’s website at the following link:
Rule 59G-4.002, Provider Reimbursement Schedules and Billing Codes (myflorida.com)
Below are the instructions for submitting FFS claim and encounter transaction adjustments:
Submit Adjustment (FFS or encounter) via X12 837 transaction:
- Adjusted claims must contain a frequency code of “7” and the 13-digit ICN of the paid claim being adjusted in the REF02 segment of the X12 837 transaction.
- For additional information on the successful processing of adjustments, please refer to the EDI companion guides on the public Web Portal.
Submit FFS Adjustment via secure Web Portal:
- Open the claim and make any necessary changes (including billed amount(s)), then click the Adjust button. If there are no changes then just click the Adjust button.
- For additional information on submitting claims via the secure Web Portal, please refer to the Direct Data Entry (DDE) Claim Form Presentations on the public Web Portal.
Managed Care Plan providers should contact the plan directly for billing questions and instructions.
