Medical billing services in Florida

Florida Medicaid is run by the Agency for Health Care Administration (AHCA). Fee-for-service claims and provider enrollment go through the Florida Medicaid Web Portal (FMMIS)¹, at portal.flmmis.com. Statewide Medicaid Managed Care (SMMC): most recipients must enroll in a Managed Medical Assistance plan, with long-term care, dental and specialty plans under the same program⁵. Mandatory enrollees who do not pick a plan are auto-assigned and get a 120-day window to change; voluntary enrollees can disenroll at any time. AHCA re-procured the MMA and dental plans, so confirm a plan's current contract and regions before you credential with it.

Fee-for-service filing limit: No later than 12 months from the date of service, the outside limit that federal Medicaid rules set for every state agency, including Florida⁷. The managed care plans set their own limits in their provider manuals; Community Care Plan, for example, denies claims received more than 180 days after the date of service.

Managed care plans⁴

• Sunshine State Health Plan (Sunshine Health)Listed by CMS in its 2024 state tables as an MMA plus long-term care plan; AHCA has since re-procured the MMA plans
• Simply Healthcare PlansAlso runs the Clear Health Alliance specialty plan
• Molina Healthcare of Florida
• Humana Medical Plan (Humana Healthy Horizons in Florida)
• Florida Community Care
• Aetna Better Health of Florida
• UnitedHealthcare of Florida
• Community Care Plan
• Liberty Dental Plan of FloridaDental plan
• Managed Care of North America (MCNA)Dental plan
• DentaQuest of FloridaDental plan

Each plan is credentialed separately, has its own portal and its own appeal route. A practice that joins Florida Medicaid through one plan is not in network with the others until each contract is in place.

Commercial payers active in Florida⁹: Florida Blue (BlueCross BlueShield of Florida), Ambetter Health, Oscar Health, UnitedHealthcare, Wellpoint, AvMed, Molina Healthcare, Cigna Healthcare. Filing windows, corrected-claim processes and appeal levels differ from one to the next, and each payer sets them out in its own provider manual; the timely filing limits table gathers verified payer deadlines with their sources.

Clean-claim payment window under Florida's prompt pay law, Florida Statutes sections 641.3155 (HMOs) and 627.6131 (health insurers): 20 days for electronic claims, 40 days for nonelectronic claims¹⁶. Within those 20 or 40 days after receipt the HMO or insurer has to pay the claim or tell the provider it is denied or contested. Both sections then require payment or denial within 90 days of receipt for an electronic claim and 120 days for a nonelectronic one, turn a claim left open past 120 or 140 days into an uncontestable obligation to pay, and charge simple interest of 12 percent per year on overdue payments. Providers must mail or electronically transfer a claim within 6 months after discharge for inpatient services or the date of service for outpatient services, and after the provider has been given the correct name and address of the patient's HMO or insurer. Section 627.6131 sets the same timelines for health insurers that section 641.3155 sets for HMOs. That window sets the pace of A/R follow-up. Once a clean claim passes it, the claim is escalated to the payer with the statute cited, and interest is requested where the law provides for it.