Florida AHCA Compliance

SMMC 3.0 · FMMIS · MPIP

Cloud Health Office ships native support for Florida’s Agency for Health Care Administration (AHCA) regulatory requirements, including the February 2025 SMMC 3.0 program rollout. Four compliance modules handle FMMIS encounter submission, 837 companion guide deviations, MPIP enhanced rates, and FL-specific tenant configuration.

Overview

Florida’s Agency for Health Care Administration (AHCA) administers the Statewide Medicaid Managed Care (SMMC) program. On February 1, 2025, AHCA launched SMMC 3.0 — new 5-year MCO contracts with enhanced requirements including:

• Mandatory assignment of all Florida Medicaid members to a managed care plan
• Enhanced prior authorization reform timelines
• Managed Medical Assistance Physician Incentive Program (MPIP) — 106.3% of Medicare rates for qualifying services to members under age 21
• Stricter encounter data submission requirements via FMMIS
• Continuity of care obligations during plan transitions

Regulatory Requirements

FL Tenant Config Schema

The TenantComplianceConfig model holds FL-specific deadlines, FMMIS credentials, and MPIP enablement. StateComplianceConfig is an embedded value object with all FL regulatory timeline values. API: GET/PUT /api/compliance-config/{tenantId}. Seed data: Data/seed/fl-ahca-config.json.

{
  "tenantId": "fl-mco-example",
  "stateCode": "FL",
  "fmmisSubmitterId": "SUBMITTER_ID",
  "fmmisInterchangeSenderId": "SENDER_ID",
  "mpipEnabled": true,
  "stateConfig": {
    "promptPayElectronicDays": 35,
    "promptPayPaperDays": 45,
    "promptPayPenaltyRateAnnual": 0.10,
    "claimAcknowledgmentDays": 0,
    "priorAuthUrgentHours": 72,
    "priorAuthStandardDays": 5,
    "appealStandardDays": 30,
    "appealExpeditedHours": 72,
    "encounterSubmissionDays": 60
  }
}

FMMIS EDI Adapter

Located in services/claims-service/EDI/Florida/. Three components:

837 Deviations Applied

• All enrollees treated as primary subscribers (no 2000C dependent loop)
• FL Medicaid Provider Number added to 2010AA loop as REF*1D
• ISA08 receiver ID set to “FMMIS”

Encounter Submission Service

Located in services/encounter-submission-service. Key behaviors:

• Background worker polls every 4 hours for pending encounter submissions
• Calculates 60-day submission deadline from claim adjudication date
• Fires encounter-deadline-warning Kafka event when deadline is within 7 days
• Stages batch files to Azure Blob (SFTP transport to FMMIS is a follow-on task)
• Processes 999 acknowledgment responses and updates submission status
• Auto-creates submission records when claims-service publishes adjudication-completed event

MPIP Rate Engine

Located in services/provider-service. Two components:

• MpipProviderQualification — tracks provider qualification per AHCA fiscal year (Oct–Sep)
• MpipRateService — applies 106.3% Medicare rate multiplier

• Bulk import endpoint for annual AHCA qualified provider list (Oct 1)
• Multiplier stored on ClaimLine.MpipMultiplierApplied for audit trail

FMMIS Encounter Submission Flow

1. Claim adjudicated (Approved/Paid)
2. AdjudicationCompletedConsumer receives Kafka event
3. EncounterSubmissionService.CreateSubmissionRecord() — SubmissionDeadline = AdjudicatedAt + 60 days, Status = Pending
4. EncounterSubmissionWorker runs every 4 hours:
   • Deadline within 7 days → Status = DeadlineWarning, publish encounter-deadline-warning event
   • Deadline within 48 hours → BuildFmmisSubmissionBatch()
5. FmmisClaimTransformer.Transform() → FmmisFileBuilder.Build() → Write to Azure Blob staging → Status = Batched → Submitted
6. ProcessAcknowledgment() processes 999 response → Status = Accepted | PartialAccept | Rejected

Target FL Medicaid MCOs

These plans operate under AHCA’s SMMC 3.0 contracts (2025–2030):

• Sunshine Health (Centene)
• Molina Healthcare of Florida
• Humana Medical Plan (Medicaid)
• Simply Healthcare Plans (Anthem)
• Staywell Health Plan of Florida (WellCare/Centene)
• Florida Community Care (LTC)

Known Gaps / Future Work

References

• AHCA SMMC 3.0 Program
• FMMIS 837P Companion Guide — publicly available from AHCA
• FL Statute §627.6131 (Prompt Pay)
• FL AHCA MPIP 2025-2026
• CMS-0057-F Prior Authorization Rule

Related Documentation