Medicaid Florida Exceptional Claim Form - Fill Online 2025

1. Click ‘Get Form’ to open the Medicaid Florida Exceptional Claim Form in our editor.
2. Begin by entering your Provider Name and Contact information, including your phone number and provider number. This information is essential for processing your claim.
3. In Section I, check the appropriate box that applies to your claim if it is more than 12 months old. Ensure you attach any required documentation, such as a copy of the Medicare EOMB or administrative hearing decision.
4. If your claim is less than 12 months old, proceed to Section II and select the relevant reason for requesting an exception. Again, attach necessary documents like the Medicare EOMB if applicable.
5. In Section III, provide any other reasons for your request that may not be covered in previous sections. Be clear and concise.
6. Finally, sign and date the form at the bottom before submitting it. Remember that a separate form is needed for each claim.

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