Florida's Medicaid managed care market means every billing operation deals with at least 4-5 payers simultaneously, each with slightly different denial rules. Here are the most common denial reasons across Florida's major payers, ranked by frequency and net dollar impact — with the fix for each.
Across All Florida Payers
- ✓CO-97 — The benefit for this service is included in the payment/allowance for another service. Most common when unbundling services that payers consider part of a global episode. Fix: review payer bundling policies before coding.
- ✓CO-4 — The service is inconsistent with the modifier used. Fix: verify modifier requirements per payer — they differ significantly between Florida Medicaid FFS, MMC plans, and Medicare.
- ✓CO-50 — Non-covered service. Fix: verify the specific service is a covered benefit under the patient's plan before delivery.
- ✓PR-96 — Non-covered charge. Patient financial responsibility. Fix: confirm eligibility and benefit details at scheduling, not after service.
Sunshine Health (Florida's Largest MMC Plan)
- ✓Missing prior authorization for home health aide services — Sunshine requires auth where FFS does not
- ✓Claims submitted beyond 90-day timely filing window — Sunshine's window is shorter than Medicare
- ✓Service code not covered under the recipient's specific plan — Sunshine has multiple products (Medicaid, Medicare Advantage, CHIP) with different benefits
Humana Medicaid Florida
- ✓90-day timely filing — same as Sunshine, aggressive compared to Medicare's 12-month window
- ✓Rendering provider not in the Humana Florida Medicaid network — NPI enrollment must be current
- ✓Authorization expired or units exceeded — Humana's auth tracking is strict; claims that exceed authorized units deny automatically
Molina Healthcare Florida
- ✓Telehealth modifier requirements — Molina has specific modifier rules that differ from CMS guidance; GT and 95 are not interchangeable for all service types
- ✓Missing coordination of benefits information for dual-eligible patients
- ✓Service not authorized under specific waiver program — Molina administers multiple Florida waiver programs with different covered services
Florida Medicaid FFS
- ✓EVV data not confirmed in Sandata before claim submission — the single largest source of home health claim rejections in Florida Medicaid FFS
- ✓Provider enrollment not current — NPI, taxonomy, and Medicaid provider ID must all match
- ✓Duplicate claim — FFS systems flag duplicates aggressively; re-submissions require specific claim adjustment reason codes
Leymax maintains a current payer rule library for all Florida MMC plans and Medicaid FFS. Our pre-submission claim scrubbing catches payer-specific denial triggers before they reach the clearinghouse.
See how we prevent denials →