Florida medicaid exceptional claim form 2026

1. Click ‘Get Form’ to open the Florida Medicaid Exceptional Claim Form in our editor.
2. Begin by entering your Provider Name and Contact information, including your phone number and provider number. This ensures that your claim is correctly associated with your practice.
3. In Section I, check the appropriate box that describes why you are requesting an exception for claims older than 12 months. Be sure to attach any necessary documentation as indicated.
4. For claims less than 12 months old, proceed to Section II and select the relevant reason for your exception request. Again, ensure all required documents are attached.
5. If applicable, provide additional reasons in Section III. Make sure to sign and date the form at the bottom before submission.
6. Finally, mail the completed form to the address provided for Exceptional Claims Processing in Tallahassee, FL.

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