Policy UpdatesSimply Healthcare Plans, Inc. - Medicaid Managed CareClear Health Alliance - Medicaid Managed CareJune 20, 2024

NPI Crosswalk Logic Change Updates

This communication applies to the Medicaid programs for Simply Healthcare Plans, Inc. (Simply) and Clear Health Alliance (CHA).

In the past, the Agency for Healthcare Administration (AHCA) reviewed claims and encounters by NPI and ZIP code to match the state Provider Master List (PML). Claims and encounters passed whenever a one-to-one match was found. This impacted providers who had more than one state Medicaid ID.

Now, AHCA reviews NPI and taxonomy first. When the taxonomy is not present or does not match what is on the state PML, the validation of the claim/encounter stops. We identified that many registered providers are submitting claims and encounters with an incorrect taxonomy or missing taxonomy, causing the claims/encounters to fail.

In addition to the logic described above, there is logic for the rendering (performing) provider that will be created to ensure the encounter acceptance/rejection process mirrors the requirement enforced by AHCA.

In the coming months, Simply and CHA will be implementing this new edit (currently in place for billing providers) for the rendering (performing) provider which will reject encounters where the rendering (performing) provider is not registered with the state based on NPI, taxonomy, and address matching.
Note: The address included on the electronic claim must be the service location (either facility address, or billing provider address if this is the same as the facility address). This address must match your PML service address with AHCA.

Provider actions

Providers need to review their claim submission process and their taxonomy on the state PML. The NPI, taxonomy, first-line address, and nine-digit ZIP code on each claim must match with what is listed on the PML. Providers have two options. They can:

  • Review the PML data and make the appropriate changes. Recommended actions:
    • Request a new Medicaid ID for the new location and/or taxonomy.
    • Update current Medicaid ID with the current location and/or taxonomy.
    • Check with your billing provider to ensure your registered address matches the address your billing provider is submitting on the electronic claim. For example, 123 Main Street is read differently than 123 Main St. #456.
  • Make changes to the claim submission. Recommended actions:
    • Ensure your billing provider/billing entity on the electronic claim uses an address that matches the PML exactly. For example, 123 Main Street is read differently than 123 Main St. #456.

Ensure your billing provider/billing entity includes the correct facility address and service locations required where the billing provider/billing entity service location for their Medicaid ID differs from the service location for your Medicaid ID.

Reference material and guidance

These are available to all providers on the state’s public website. All these resources have been communicated to providers regarding the state changes since last year.

Important reminders

In addition to having the correct taxonomy submitted on the claim, it is crucial that the address and ZIP code match to what AHCA has on the PML for the provider. Often, we see there are multiple Medicaid IDs for the same location and the address and/or taxonomy does not align with the information being submitted on the claim.

Additional resources:

  • AHCA FLMMIS website: All public information and documentation is found at the Florida Medicaid web portal.
  • By logging in to the web portal, providers can make any changes to their Medicaid ID registration information.
  • Providers can download the NPI Initiative FAQ PDF. Page six shows the new logic where taxonomy is the second level of validation. Any provider who has more than one Medicaid ID will hit this taxonomy validation where the taxonomy must match the state Medicaid ID registration.

To find the PML, Provider Registration, and Registration documents, access the menu pictured below from the drop down on the main page.

Contact us

The Availity Essentials Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity, go to Availity.com and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.

Simply Healthcare Plans, Inc. is a Managed Care Plan with a Florida Medicaid contract. Simply Healthcare Plans, Inc. dba Clear Health Alliance is a Managed Care Plan with a Florida Medicaid contract.

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PUBLICATIONS: July 2024 Provider Newsletter