Florida Billing Reference

Medical Billing in Florida: Payer Landscape, Medicaid & Timely Filing

Florida Medicaid runs Statewide Managed Medical Assistance (MMA) through plans including Aetna Better Health, Humana Medical Plan, Molina, and WellCare. With one of the highest uninsured rates in the US (11%+) and a strict 95-day timely filing window for Medicaid claims, Florida billing teams face an unusually tight operational cadence.

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Medical Billing in Florida: The Short Version

Florida's billing landscape is defined by two forces: the Statewide Medicaid Managed Care (SMMC) program, which routes nearly all Medicaid beneficiaries through contracted plans, and one of the highest Medicare Advantage penetration rates in the nation. Florida Blue (a GuideWell company) is the dominant commercial payer, and the state's large retiree population makes MA plan rules — prior authorization above all — a daily operational reality for most practices.

Payer Landscape

Major Payers in Florida

Payer	Type	What Billing Teams Should Know
Florida Blue	Commercial / Blue plan	Dominant commercial payer; GuideWell company; myBlue HMO products have narrow networks
UnitedHealthcare	Commercial / MA	Major employer and MA book statewide
Humana	Medicare Advantage	Headquartered market; among the largest MA payers in FL; strict 90-day commercial filing
Aetna	Commercial / MA	Significant MA growth in FL metros
Cigna	Commercial	Employer self-funded concentration
AvMed	Regional commercial	Florida-only payer; distinct credentialing
Florida Medicaid (AHCA)	Medicaid	SMMC plans control most volume; FFS window 12 months

Medicaid Structure

Florida Medicaid (SMMC): Managed Care Plans

Administered by the Agency for Health Care Administration (AHCA). The patient's plan assignment — not just Medicaid eligibility — determines the portal, prior-auth list, and filing rules that apply.

Plan	Notes
Sunshine Health (Centene)	Largest SMMC footprint; also operates Ambetter marketplace plans
Humana Healthy Horizons	SMMC plan from Florida’s largest MA payer
Simply Healthcare (Elevance)	SMMC and MA presence, South Florida concentration
UnitedHealthcare Community Plan	SMMC managed medical assistance
Molina Healthcare of Florida	SMMC regions in central/south Florida

Filing Deadlines

Timely Filing Limits for Florida Claims

Initial-claim windows for the payers Florida practices bill most. Commercial limits are contract-specific — always confirm against your provider agreement and the payer's current manual.

Payer	Timely Filing Limit	Notes
Florida Medicaid (FFS)	12 months from date of service	SMMC plans set their own (often shorter) windows — typically 180 days
Medicare (original)	12 months from date of service	Set by federal law; no contract variation
UnitedHealthcare (commercial)	90 days from date of service	Contract-specific; some plans allow 180
Aetna (commercial)	120 days from date of service	Contract-specific; verify provider agreement
Cigna (commercial)	90 days from date of service	Contract-specific; verify provider agreement
Humana (commercial)	90 days from date of service	Among the strictest; Medicare Advantage differs

Verified against payer publications at time of writing (July 2026). Filing limits change by contract and plan year — treat this table as a starting point, not a substitute for the payer manual. See our methodology.

FL-Specific Rules

Florida Billing Realities to Know

Medicare Advantage Density

Florida has among the highest MA penetration in the US. Practices see more prior-auth requirements, plan-specific referral rules, and post-payment audits than in low-MA states.

SMMC Regional Structure

SMMC operates in defined regions — plan availability and assignment differ by county, and a plan’s PA list in one region may differ from another.

Snowbird Seasonality

Seasonal residents carry out-of-state Blue plans and MA plans. BlueCard claims and out-of-area MA billing are routine and frequently mishandled.

AHCA Audit Posture

Florida’s Medicaid integrity program is active; documentation standards for high-volume codes deserve internal audit before AHCA does it for you.

Frequently Asked Questions

Florida Medicaid (SMMC) allows 12 months from date of service for initial claims, administered by the Agency for Health Care Administration (AHCA). Managed care plans operating in Florida may apply shorter contractual windows, so always verify each plan's provider manual.

Sunshine Health (Centene), Humana Healthy Horizons, Simply Healthcare (Elevance), UnitedHealthcare Community Plan, Molina Healthcare of Florida. Each plan maintains its own provider portal, prior authorization list, and claim submission rules — the patient's plan assignment, not just Medicaid status, determines how a claim must be billed.

Florida Blue, UnitedHealthcare, Humana, Aetna, Cigna, alongside Medicare and Florida Medicaid (SMMC). See the payer landscape table on this page for what billing teams should know about each.

Seasonal residents often carry Blue plans from other states. Those claims are filed to Florida Blue under the BlueCard program but adjudicated by the member’s home plan — which controls the fee schedule, filing window, and appeal path. Misrouting BlueCard claims is a common and preventable denial source in Florida.

Code Reference

Common Codes Billed in This State

Frequently billed codes in this state’s payer environment, with notes on state-specific rules and common denial patterns.

Code	Description	State-Specific Note
99213	Office visit, est. patient — level 3	MMA plan determines fee schedule; verify member’s plan
99214	Office visit, est. patient — level 4	High volume under Aetna Better Health and WellCare MMA
99215	Office visit, est. patient — level 5	Document complexity; Humana FL audit rate is above average
Mod. GT	Telehealth — real-time audio/video	Required for Florida Medicaid telehealth billing
G0463	Hospital outpatient clinic visit	Common for Federally Qualified Health Centers across FL
CO-4	Service billed to wrong payer / untimely	95-day Medicaid window is tight; track submission dates carefully

Codes and reimbursement rates change annually. Verify current fee schedules with each payer before billing. Full code lookup →