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Florida Medicaid non-covered services and procedures – a quick review


Service Exclusions from Florida Physician Services Coverage and Limitations Handbook

*Medicaid does not reimburse for immunization services for recipients who are 21 years of age and older.

*Medicaid does not reimburse providers for venipuncture, collection, handling or transportation of specimens. This is considered part of the global fee for the service.

Medicaid does not reimburse for the interpretation of arterial blood gases.

*Medicaid does not reimburse for spirometry.

Analysis of arterial blood gases, 82800-82810, is not covered when performed in addition to anesthesia.

CVP insertion is not covered when performed in conjunction with Swan-Ganz insertion, 93503, unless documented at separate distinct sites.

Intravenous pain management by patient controlled analgesia (PCA) is not reimbursable by Medicaid.

Medicaid does not reimburse for mobile cardiovascular services

Medicaid does not reimburse for any technical component reimbursements for procedure codes other than radiology codes

Medicaid does not reimburse for procedure codes that provide diagnostic data that are duplicative of another more comprehensive procedure code performed on the same date of service.

Medicaid does not reimburse radiology and ultrasound services to mobile providers.

*Florida Medicaid will not reimburse for procedures when submitted with Modifier 76 other than the radiology codes (70000-79999)
Medicaid does not reimburse for insertion of intracatheters, PICC lines, infusea-ports, heparin locks or other such methods for delivering intravenous infusions in addition to the prolonged intravenous infusion therapy procedure codes.

*Medicaid does not reimburse visits for second opinions.

Medicaid does not reimburse services furnished to Florida Medicaid recipients when they are out of the country.

Medicaid does not reimburse for telephonic communication to other providers, caregivers, or recipients.

*Medicaid does not reimburse services related to acupuncture.

*Medicaid does not reimburse anesthesiology supervision of CRNAs performing monitored anesthesia care (MAC) or conscious sedation

Medicaid does not reimburse for organ transplant procedures involving living donor organs except for kidney transplants

Medicaid does not reimburse home health services solely due to age, environment, convenience or lack of transportation.

Newborn visits

Medicaid does not reimburse for visit services for a normal newborn who remains in the hospital after three days.

*Medicaid does not reimburse for discharge day management for a normal newborn.

Medicaid does not reimburse for a newborn visit and Child Health Check-Up screening for the same provider, same recipient, and same day of service.

Psychiatric services

Medicaid does not reimburse for any psychiatric services, including pharmacologic management of medications, provided in nursing facilities, skilled nursing facilities,
domiciliary homes, or assisted living facilities.

Medicaid does not reimburse for telephonic psychiatric consultations or services. This includes telephonic communication to other providers, caregivers or recipients.

Medicaid does not reimburse psychiatric services rendered at any other place of service including nursing facilities or custodial care facilities

Non-reimbursable Consultation Visits

Medicaid does not reimburse for a consultation visit in addition to an office, home, nursing facility, custodial care facility or hospital visit on the same day of service, by the same provider.

*Medicaid does not reimburse for consultations rendered in nursing or custodial care facilities.

Medicaid does not reimburse for the following:

• Consultations for a second opinion, or

• Consultations and surgical procedures on the same day.

Ophthalmological Services

*Medicaid does not reimburse for both an evaluation and management visit and a general ophthalmological visit on the same day for the same recipient.

Medicaid does not reimburse for eyeglasses or eyeglass repairs for recipients age 21 and older.

Medicaid does not reimburse for routine vision re-examinations, which includes CPT evaluation and management codes and general ophthalmological visits, performed exclusively for checking an eyeglasses prescription dispensed by the same provider within the previous 30 days.

A routine eye exam in the absence of a reported vision problem, an illness, disease, or injury is not reimbursable

Non-FDA Approved Medications

*Medicaid does not reimburse for non-FDA approved medications.

Medicaid does not reimburse procedures that are experimental or when non-FDA approved medications are included in the procedures.

Provider Write off

*Medicaid does not reimburse copayments, coinsurance, or deductibles for any services provided under a Medicare Advantage Plan.

Medicaid does not reimburse for services provided to recipients when they are out of the United States.

Medicaid does not reimburse for services rendered by providers who are not in the United States.

Medicaid does not cover any of the coinsurance days for inpatient hospital stays.

Medicaid does not reimburse a claim because:

1. Medicare’s payment is the same or more than Medicaid’s fee for the service;

2. The service is not covered by Medicaid;

3. The recipient is eligible as a Qualified Medicare Beneficiary (QMB) or QMB with full Medicaid coverage (QMB+) for the Medicare coinsurance or deductible.

A provider who bills Medicaid for reimbursement of a Medicaid-covered service may not bill the recipient, the recipient’s relatives, or any person or persons acting as the recipient’s designated representative.

Please click here to know more about Florida Medicaid Physician Services Coverage and Limitations

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