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Claims Submission Protocols

Prestige Health Choice will reimburse providers for the delivery of covered services as follows:

  1. Claims are considered received on the date the claims are received by Prestige.
  2. Providers must mail or electronically transfer (submit) the claim to Prestige Health Choice within the time frame allowed by their contract (generally 90 days for physicians and 180 days for hospitals)
  3. Non-contracted providers must mail or electronically transfer (submit) the claim to Prestige Health Choice within twelve  (12) months of:

a. The date of service or discharge from an inpatient setting; or,
b. The date that the provider has been furnished with the Enrollee's correct name and address

Prestige Health Choice will reimburse providers for Medicare deductibles and co-insurance payments for Medicare dually eligible members.

In accordance with s.409.912, F.S., Prestige Health Choice will reimburse any hospital or physician that is outside its authorized geographic service area for Prestige Health Choice authorized services provided by the hospital or physician to Enrollee:

  1. At a rate negotiated with the hospital or physician; or,
  2. The lesser of the following:

a. The usual and customary charge made to the general public by the hospital or physician;
b. The Florida Medicaid reimbursement rate established for the hospital or physician; or
c. The local State Medicaid reimbursement rate established for the hospital or physician for out-of-state services.