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Centurion of Florida, LLC

Provider Manual

Version 3.1

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Table of Contents
CENTURION OF FL Overview ......................................................................................................................... 5
CENTURION OF FL Guiding Principles ........................................................................................................... 5
CENTURION OF FL Approach......................................................................................................................... 5
CENTURION OF FL Summary ......................................................................................................................... 6
Working with CENTURION OF FL .................................................................................................................. 6
CENTURION OF FL Regional Office Key Utilization Management Staff .................................................... 6
FDOC Facility Names and Contact Numbers ............................................................................................. 7
CENTURION OF FL On-Site Services .............................................................................................................. 8
On-Site Practitioners ................................................................................................................................. 9
On-Site Practitioner Availability ................................................................................................................ 9
24-Hour Access ......................................................................................................................................... 9
Monitoring Healthcare Services.................................................................................................................. 10
Specialty Care, Emergency Department and Hospitalization Accessibility/Coordination .......................... 10
Specialty Care Prior Authorization .............................................................................................................. 11
Emergency Department Services ................................................................................................................ 11
Hospitalization ............................................................................................................................................ 11
Specialty Provider Responsibilities ............................................................................................................. 12
Working with the Inmates .......................................................................................................................... 12
Continuity of Care ....................................................................................................................................... 12
Specialist Appointment Access Standards .................................................................................................. 13
Hospital Responsibilities ............................................................................................................................. 13
Provider Assistance with Public Health Services ........................................................................................ 14

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Credentialing Requirements ....................................................................................................................... 14
Recredentialing ........................................................................................................................................... 14
Provider/Facility Site Review ...................................................................................................................... 14
Eligibility ...................................................................................................................................................... 15
Billing and Claims ........................................................................................................................................ 15
General Billing Guidelines ....................................................................................................................... 15
Billing the Inmate .................................................................................................................................... 16
Clean Claim Definition............................................................................................................................. 16
Non-Clean Claim Definition..................................................................................................................... 16
Timely Filing ............................................................................................................................................ 17
Electronic Claims Submission.................................................................................................................. 17
Paper Claims Submission ........................................................................................................................ 17
Provider Portal……………………..................................................................................................................18
Unsatisfactory or Claim Payment Concerns............................................................................................ 18
Provider Relations Assistance ..................................................................................................................... 18
Provider Updates .................................................................................................................................... 19
Provider Complaints................................................................................................................................ 19
CENTURION OF FL Pharmacy Program ....................................................................................................... 19
Pharmacy and Therapeutics (P&T) Committee ...................................................................................... 20
Medical Records.......................................................................................................................................... 20
Overview ................................................................................................................................................. 20
Release of Medical Records .................................................................................................................... 20
Medical Records Audits .......................................................................................................................... 21
CENTURION OF FL Medical Management Department .............................................................................. 21

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Overview and Medical Necessity ............................................................................................................ 21
Prior Authorization Overview ................................................................................................................. 22
On-Site Practitioner Referral for Specialty Service ................................................................................. 22
Specialist Referral to Specialist for Treatment or Second Opinion......................................................... 23
Process to Request Follow-Up Specialty Services ................................................................................... 23
Self-Directed Care ................................................................................................................................... 23
Prior Authorization Response TImeline………………………………………………………………………………………………23
Medical Necessity ................................................................................................................................... 24
Review Criteria ........................................................................................................................................ 24
Requirements for Providers to Notify CENTURION OF FL Medical Management Department ................. 25
Emergency Services ................................................................................................................................ 25
Notification of Observation Stays ........................................................................................................... 25
Concurrent Review.................................................................................................................................. 25
Discharge Planning .................................................................................................................................. 26
Retrospective Review.............................................................................................................................. 26
Summary ..................................................................................................................................................... 27

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CENTURION OF FL Overview

Welcome to the CENTURION OF FLORIDA, LLC (Centurion of FL) Provider Manual.
CENTURION OF FL is a company established by two of the oldest and most respected names in
correctional healthcare and managed Medicaid services: MHM Services, Inc. and Centene Corporation.
This innovative partnership brings a combination of recruiting, program management and proven care
principles to both the on-site and off-site correctional healthcare operations.
CENTURION OF FL has entered into an agreement with the Florida Department of Corrections (FDOC) to
provide comprehensive healthcare services to inmates throughout the state’s correctional system.
CENTURION OF FL is committed to building collaborative partnerships with Providers.
CENTURION OF FL serves the FDOC consistent with our core philosophy that quality correctional
healthcare requires coordination of care provided within the correctional facility and the services
provided “outside the walls.” Headquartered in Tallahassee, all Centurion of FL employees that work
within FDOC and Providers are based in Florida.

CENTURION OF FL Guiding Principles
In your dealings with CENTURION OF FL you will find that we apply the following guidelines to all our
interactions. We…
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Provide access to high quality, accessible, cost-effective healthcare
Perform our functions with integrity, operating at the highest ethical standards
Build mutual respect and trust in our working relationships
Create communication that is open, consistent and two-way
Embrace diversity of people, cultures, and ideas
Encourage innovation to challenge the status quo
Stress teamwork and meeting our commitments to one another

Also, please note that CENTURION OF FL welcomes open Provider communication regarding appropriate
treatment alternatives. CENTURION OF FL does not penalize Providers for discussing medically
necessary, appropriate care or treatment options with our on-site primary care physicians.

CENTURION OF FL Approach
Recognizing that a strong healthcare program is predicated on building mutually satisfactory
associations with Providers, CENTURION OF FL is committed to:
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Working as partners with participating Providers
Performing our administrative and clinical responsibilities in a superior fashion

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As much as possible, CENTURION OF FL programs, policies and procedures are designed to minimize the
administrative responsibilities in the management of care, enabling the Provider to focus on the
healthcare needs of their patients.

CENTURION OF FL Summary
CENTURION OF FL’s philosophy is to provide access to high quality healthcare services by combining
the expertise of on-site primary care practitioners and specialty providers/specialty services with a
highly successful, experienced managed care administrator. CENTURION OF FL believes that successful
patient outcomes are the result of providing care that is medically necessary, rendered in the
appropriate setting and at the appropriate interval.
It is the policy of CENTURION OF FL to conduct its business affairs in accordance with the standards
and rules of ethical business conduct and to abide by all applicable federal and Florida laws.
CENTURION OF FL takes the privacy and confidentiality of health information seriously. We have
processes, policies and procedures to comply with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and Florida Privacy Law requirements.

Working with CENTURION OF FL
For your convenience, we have included a quick reference guide to provide an overview of your role in
providing care and recommendations for care as part of your CENTURION OF FL contract. The
information below and throughout this manual will include information that should assist you and your
day-to-day operations staff. The information includes:
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Contact information for CENTURION OF FL Medical Management Department (Utilization
Management staff)
Name and contact number for Department of Correction sites
Claims submission and contact information
Role of the CENTURION OF FL on-site practitioner
The referral process and your role
Information required by CENTURION OF FL on-site healthcare team for continuity and provision
of care

CENTURION OF FL Regional Office Key Utilization Management Staff
CENTURION OF FL Medical Management
Department
(Utilization Management Staff)
CENTURION OF FL Statewide Medical Director
CENTURION OF FL Chief Nursing Officer
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1-844-243-0795

1-844-243-0795
1-844-243-0795

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FDOC Facility Names and Contact Numbers
Region
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Site Name
Apalachee East Unit
Apalachee West Unit
Calhoun Correctional Institution
Century Correctional Institution
Franklin Correctional Institution
Gadsden Re-Entry Center
Gulf Correctional Institution
Holmes Correctional Institution
Jackson Correctional Institution
Jefferson Correctional Institution
Liberty Correctional Institution
Northwest Florida Reception Center
Okaloosa Correctional Institution
Quincy Annex
Santa Rosa Correctional Institution
Taylor Correctional Institution
Wakulla Correctional Institution
Walton Correctional Institution
Baker Correctional Institution
Baker Re-entry Center
Columbia Correctional Institution
Cross City Correctional Institution
Florida State Prison
Hamilton Correctional Institution
Lancaster Correctional Institution
Lawtey Correctional Institution
Madison Correctional Institution
Mayo Correctional Institution
New River Correctional Institution
Putnam Correctional Institution
Reception and Medical Center
Suwannee Correctional Institution
Tomoka Correctional Institution
Union Correctional Institution
Avon Park Correctional Institution
Central Florida Reception Center
DeSoto Correctional Institution
Florida Women’s Reception Center

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City
Sneads
Sneads
Blountstown
Century
Carrabelle
Havana
Wewahitchka
Bonifay
Malone
Monticello
Bristol
Chipley
Crestview
Quincy
Milton
Perry
Crawfordville
DeFuniak Springs
Sanderson
Sanderson
Lake City
Cross City
Raiford
Jasper
Trenton
Lawtey
Madison
Mayo
Raiford
East Palatka
Lake Butler
Live Oak
Daytona Beach
Raiford
Avon Park
Orlando
Arcadia
Ocala

Phone #
(850) 718-0688
(850) 718-0577
(850) 237-6500
(850) 256-2600
(850) 697-1394
(850) 539-2440
(850) 639-1000
(850) 547-8600
(850) 569-5260
(850) 342-0500
(850) 643-9400
(850) 773-6100
(850) 682-0931
(850) 627-5400
(850) 983-5800
(850) 838-4000
(850) 410-1895
(850) 951-1300
(386) 719-4500
(386) 719-6300
(386) 754-7600
(352) 498-4741
(904) 368-2500
(386) 792-5151
(352) 463-4100
(904) 782-2000
(850) 973-5300
(386) 294-4500
(904) 368-1500
(386) 326-6800
(386) 496-6000
(386) 963-6530
(386) 323-1070
(386) 431-2000
(863) 452-8801
(407) 207-7777
(863) 494-3727
(352) 840-8000

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Hardee Correctional Institution
Hernando Correctional Institution
Lake Correctional Institution
Lowell Correctional Institution
Marion Correctional Institution
Polk Correctional Institution
Sumter Correctional Institution
Zephyrhills Correctional Institution
Charlotte Correctional Institution
Dade Correctional Institution
Everglades Correctional Institution
Homestead Correctional Institution
Martin Correctional Institution
Okeechobee Correctional Institution
South Florida Reception Center

Provider Manual

Bowling Green
Brooksville
Clermont
Ocala
Ocala
Polk City
Bushnell
Zephyrhills
Punta Gorda
Florida City
Miami
Florida City
Indiantown
Okeechobee
Doral

(863) 767-3100
(352) 754-6715
(352) 394-6146
(352) 690-8900
(352) 401-6400
(863) 984-2273
(352) 569-6100
(813) 782-5521
(941) 833-8100
(305) 242-1900
(305) 228-2000
(305) 242-1770
(772) 597-8100
(863) 462-5400
(305) 591-9567

CENTURION OF FL On-Site Services
Most on-site Healthcare Services Units operate 24 hours a day, 7 days a week. The type of staff used to
provide services besides practitioner staff include registered nurses, licensed practical nurses, certified
nurse assistants, medical assistants, medical records clerks, and secretarial/administrative assistant
staff.
The FDOC has a licensed 120-bed hospital, an ambulatory surgery center, and a cancer treatment center
on location at the Reception and Medical Center (RMC) in Lake Butler.
The sites also provide on-site mental health and dental staff to allow a full complement of on-site care
capabilities. Sites are managed by a clinical and administrative team that may include a Medical
Director, Director of Nursing, and/or Health Services Administrator.
Medication services include provision of all practitioner ordered medications. These are managed onsite and generally provided by single dose administration. There are medical infirmaries which are
staffed with nursing staff 24 hours a day, 7 days a week to allow provision of higher level of medical care
such as IV management, wound care, and pre/post op care.
The goal of health services within a correctional services contract is to perform as much care/service onsite to minimize the need to transport inmates outside of the facility. We strive to provide appropriate
level of care and services while minimizing the risk to public safety by transporting inmates to outside
service providers.
Healthcare services that are routinely provided by on-site services and/or mobile service providers
include:

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CLIA waivered tests such as blood glucose monitoring, urine pregnancy tests, blood guaiac tests,
etc. Sites also draw all routine labs. These labs are drawn, prepared, picked-up, and results
completed/returned by a contracted lab vendor.
Radiology services include routine chest, and extremity radiographs. Some sites may also have
availability of services provided by a mobile vendor for ultrasound, MRI, mammography, etc.
Dialysis services

On-Site Practitioners
Practitioners providing care can include a combination of physicians, nurse practitioners and
physician assistants. On-site practitioners are CENTURION OF FL employees and serve as the
primary care providers and medical home for the management of inmate patient care.
Site practitioners are responsible for providing/performing care and management of urgent and routine
medical care. They are also responsible for care and management of inmate patients with chronic
disease. Site practitioners are also responsible for requesting and managing inmate patient specialty
care. Inmate patients are not allowed to ‘self-refer’ for a specialty provider/service as allowed in the
community.
The on-site practitioners submit requests for specialty service based on the CENTURION OF FL prior
authorization list (PAL) for services identified as requiring medical necessity determination. CENTURION
OF FL uses InterQual and other evidence-based criteria to assess medical necessity of the request. Our
program uses a two level review system where trained utilization management nurses perform Level 1
review. Any request not meeting criteria for Level 1 approval is deferred to our CENTURION OF FL
Statewide Regional Medical Director for final determination

On-Site Practitioner Availability
Availability is defined as the extent to which CENTURION OF FL employs the appropriate type and
number of practitioners necessary to meet the needs of the inmate patient population housed in the
institution. As part of our contract with FDOC, CENTURION OF FL provides all the on-site practitioner
staff. Most on-site practitioner staff is provided Monday through Friday during the day; however, larger
sites with more complex inmate patients may include evening and/or weekend coverage. Hours of
practitioner time on-site can range from 4 hours/week for a very small site to 80 hours+/week for larger
sites.

24-Hour Access
Regardless of the assigned staffing at the site, CENTURION OF FL provides access to on-call
practitioner(s) 24 hours a day, 7 days a week. Access to a provider can include a practitioner returning
to the facility for such things as suturing.

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Monitoring Healthcare Services

CENTURION OF FL monitors the quality of our healthcare services in numerous ways to include the
following:

Department

Data Available

Description

Frequency of
Monitoring

On-site
Practitioner
Availability

Ensures that CENTURION OF FL employs the
appropriate type and number of on-site
practitioners and specialty care
providers/services necessary for appropriate
Specialty Provider and timely access to care.
Analyzes a variety of reports to determine if
and Specialty
Service Availability additional Providers may be required

Ongoing

Prior Auth &
Concurrent
Review

Ensures prior authorization and management
of care based on evidence based practice
guidelines

Daily

On-site Quality
Improvement
Monitoring

Complaints

Monitors provision of on-site and off-site
access to care; tracks and trends inmate
complaints and grievances.

Quality
Improvement
Committee
(QIC)

Audits
Process and
Outcome Studies

Summary information is reported for review
and recommendation at the QIC and is
incorporated into CENTURION OF FL’s annual
assessment of quality improvement activities

Network &
Contract
Management

Medical
Management/
UM

Ongoing
Analyzed
Quarterly
Meetings at
least
Quarterly

Specialty Care, Emergency Department and Hospitalization
Accessibility/Coordination
As part of our health services contract, CENTURION OF FL has a Medical Management Department. The
department includes utilization management staff performing prior authorization, concurrent review,
retrospective reviews, appeals management, and other utilization review activities.

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Specialty Care Prior Authorization
On-site practitioners are responsible for requesting any services requiring prior authorization.
Therefore, prior to the inmate being scheduled for an appointment, the service requested, such as
‘initial evaluation and treatment recommendations’ will have been authorized. Upon return from a
specialist visit, the on-site practitioner will review the evaluation and recommendations from the
specialist. Based on the recommendations, the on-site practitioner may submit a new request for
additional services that were recommended as part of the initial specialty consultation. You, as the
specialist, are not responsible for requesting the prior authorization.

Emergency Department Services
Emergency department visits do not require prior authorization. If an inmate patient is sent to your
emergency department for services, the on-site nursing staff will notify you that the inmate is in route to
your facility and provide a report regarding the patient’s current care/status. Inmates presenting to the
emergency room will be transported by one or two correctional officers who will stay with the inmate
throughout the course of the emergency department visit.
Our on-site nursing supervisor will routinely make contact with the emergency department requesting
updates for prolonged visits. If it is determined the inmate will require hospitalization, it is important to
contact the referring site’s healthcare nursing supervisor. If the inmate requires transfer to another
institution, you will need to work in conjunction with the correctional officers and site healthcare staff
regarding the transfer. Inmates requiring transfer to an inpatient bed or inpatient facility will be
followed by CENTURION OF FL utilization management staff.

Hospitalization
Pre-planned hospitalizations require prior authorization. The prior authorization process is initially
managed by the on-site practitioner. Upon admission to the hospital, CENTURION OF FL utilization
management staff should be notified. While the on-site nursing staff provides notification to the
CENTURION OF FL utilization management staff, we also request that the utilization review staff at the
inpatient facility provide notification regarding the inmate patient admission to the facility.
Management of concurrent review of hospitalized inmate patients is coordinated by the CENTURION OF
FL utilization management staff. Our staff coordinates review with hospital utilization staff and provides
necessary updates for the on-site practitioner and nursing staff. CENTURION OF FL utilization
management staff also assists with coordinating discussions related to discharge planning. The goal of
discharge planning is to discharge the inmate back to the facility as soon as medically indicated;
remembering that discharge planning may include release back to one of the correctional facilities that
has infirmary capabilities.

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Specialty Provider Responsibilities
Specialty services are obtained within the CENTURION OF FL network upon approval of the prior
authorization request initiated by the on-site practitioner. Specialists may complete diagnostic tests if
part of the authorized service. It is important to remember that when coordinating scheduling, the onsite staff should be informed of results of testing and patient history that may be required as part of the
specialty visit. These documents, test results, radiology exams, etc. will be sent with the inmate for your
review.
If an immediate need arises during the visit to your office and you feel additional services, evaluation or
testing may be required immediately; you will be required to contact the CENTURION OF FL Medical
Management Department to request prior authorization for those services. This would include such
requests as, referral to another specialist or admission to the hospital. Prior authorization is not
required in a true emergency situation. However, all non-emergency inpatient admissions require prior
authorization from CENTURION OF FL.
Please call the Utilization Management team at 1-844-243-0795 for prior authorization before
performing any tests or procedures that are not part of the original authorization for this visit.

Working with the Inmates
The inmate patient will be accompanied by one or two correctional officers whenever he/she comes for
an appointment. The officers transporting will work closely with you and your office staff to provide
privacy for your other patients. CENTURION OF FL and FDOC will work with you to minimize any
disruption to your other patients.
The transporting correctional officer will provide you and your staff with a sealed envelope that includes
the inmate patient’s confidential medical record. The packet may also include a document on which you
can briefly document the synopsis of the encounter/visit. If a document is not included, simply
document the note on a standard progress note from your office and include a copy with the returning
records. All medical record information should be placed back in the envelope, re-sealed and provided
to the transporting correctional officers prior to leaving your office.
When working with the inmate patient, it is important that you do not share any information with
him/her specific to follow-up recommendations and particularly follow-up appointment dates, if already
and/or previously scheduled. If at any point you realize that you have informed the inmate patient of an
upcoming appointment date and/or time, it is important that you notify the healthcare unit immediately
to permit the appointment to be rescheduled.

Continuity of Care
Since CENTURION OF FL on-site practitioners are responsible for continuity of care, it is extremely
important that they obtain timely and thorough documentation from you, as the specialist, related to

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your evaluation and treatment recommendations for the inmate patient. Therefore, important
responsibilities of you as the specialist include:
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Coordinate the inmate patient’s care with the on-site practitioner
Complete written evaluation/report and return as part of the inmate patient’s visit
Provide the on-site practitioner with complete consult report and other appropriate records
within 5 business days of seeing the inmate patient

Specialist Appointment Access Standards
Timely access to appointments for inmate patients requiring evaluation and/or follow-up care is
important to providing acceptable access to services as well as to maintaining positive outcomes.
CENTURION OF FL staff responsible for coordinating scheduling will work with your office scheduler or
designee to identify a routine process for scheduling, including routine times/days of the weeks that
may be coordinated or set aside for easier access to appointments.
Our contracts routinely require that specialty appointments be completed within a designated
timeframe from the time of their prior approval by our utilization management staff. Our Utilization
Management staff will work closely with you to access services within our specified time frames.
CENTURION OF FL will monitor appointment timeliness and access to specialty services as part of our
ongoing Quality Improvement Program. Issues specific to access and timeliness will be discussed with
individual providers and/or services if required.

Hospital Responsibilities
CENTURION OF FL utilizes a network of hospitals to provide services to inmates. Hospitals providing
services as part of the CENTURION OF FL network will work with Utilization Management staff for the
following:
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Obtain authorization for inpatient services and non-emergent outpatient services except for
emergency stabilization services
Notify CENTURION OF FL Medical Management Department of all maternity admissions upon
admission and all other admissions by close of the following business day
Notify CENTURION OF FL Medical Management Department of all newborn deliveries on the
same day as the delivery. Note: CENTURION OF FL is not responsible for the payment of
newborn services.
Perform concurrent review and discharge planning in conjunction with CENTURION OF FL
utilization management staff
Assist in determining most appropriate and lowest level of care to provide medically necessary
care
Assist in providing continuity of care from hospital facility back to the correctional institution.

CENTURION OF FL network hospitals should refer to their contract for complete information regarding
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the hospital’s obligations and reimbursement.

Provider Assistance with Public Health Services
CENTURION OF FL is required to coordinate with public health entities regarding the provision of
public health services. Providers must assist CENTURION OF FL in these efforts by working with the
CENTURION OF FL Chief Nursing Officer or designee in:
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•

Complying with public health reporting requirements regarding communicable diseases
and/or diseases which are preventable by immunization as defined by Florida law
Assisting in the notification or referral of any communicable disease outbreaks involving inmate
patients to the local public health entity as defined by Florida law
Assisting in the notification or referral to the local public health entity for tuberculosis
contact investigation, evaluation, and the preventive treatment of persons with whom the
inmate patient has come into contact.
Assisting in referring inmate patients to the local public health entity for STD/HIV contact
investigation, evaluation, and preventive treatment of persons whom the inmate patient has
come into contact.

Credentialing Requirements
Physicians and applicable ancillary providers must complete the credentialing process to be a
participating provider with CENTURION OF FL. CENTURION OF FL recognizes the credentialing
information supplied by CAQH if the provider is already registered. A single-page demographic form is
the only requirement for CAQH participating providers.
Credentialing materials can be found in the Provider section of the Centurion website at:

www.centurionmanagedcare.com

Recredentialing
Specialty providers must comply with the recredentialing policy of one JCH accredited facility at a
minimum.

Provider/Facility Site Review
Site visits are performed on a case-by-case basis in cooperation with the provider, provider practice or
inpatient facility. Site visits will be performed by CENTURION OF FL Medical Management Department
staff. Site visits will be coordinated, as indicated, with the provider office management staff and/or
inpatient utilization management staff prior to the visit. CENTURION OF FL Medical Management

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Department staff will work with designated provider/facility staff to define reason/purpose of the visit
to allow for proper coordination and provision of information required, if indicated.

Eligibility
Eligibility has a slightly different meaning in a correctional system. Eligibility is tied directly to the
inmate being housed and/or ‘on count’ at a FDOC facility. Therefore, inmates are considered ‘eligible’
for authorized services from the date of incarceration to the date of release from the FDOC. It is
important to understand that there may be times when inmates are released from facilities and then,
may be re-arrested and returned to the FDOC system. If this occurs, the inmate is not eligible for
CENTURION OF FL payment of services during the time they are released from the facility until rearrested.
It is important to ensure that your staff that manages scheduling understands that an inmate will never
contact them directly to schedule an appointment. Appointment scheduling will always be completed
for services being authorized/paid for by CENTURION OF FL through a CENTURION OF FL healthcare staff
member. Inmates will be escorted by FDOC correctional officers for all appointments. If a person
presents without a FDOC escort, the Provider must call the CENTURION OF FL Medical Management
Department to determine whether the person is still incarcerated.
CENTURION OF FL is not financially responsible for services the person receives prior to or upon
discharge from the FDOC. If you have questions, it is best to contact Medical Management regarding
the inmate’s eligibility for services. CENTURION OF FL is not responsible for the services provided to a
newborn of a FDOC inmate.

Billing and Claims
General Billing Guidelines
CENTURION OF FL processes claims in accordance with applicable State prompt pay requirements.
Physicians, other licensed health professionals, facilities, and ancillary Provider’s contract directly with
CENTURION OF FL for payment of covered services.
It is important that Providers ensure CENTURION OF FL has accurate billing information on file.
Please confirm with your Provider Relations Department that the following information is current in
our files:
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Practitioner or Provider Name (as noted on current W-9 form)
National Provider Identifier (NPI)
Tax Identification Number (TIN)
Taxonomy Code
Physical location address (as noted on current W-9 form)
Billing name and address (if different)

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Providers must bill with their NPI number in box 24Jb on the CMS1500 (HCFA) or box 56 on the
CMS1450 (UB04). We encourage Providers to also bill their taxonomy code in box 24Ja and appropriate
ID qualifier in 24I to avoid possible delays in processing. Claims missing the requirements will be
returned and a notice sent to the Provider, creating payment delays. Such claims are not considered
“clean,” and therefore cannot be accepted into our system.
We recommend that Providers notify CENTURION OF FL in advance, but no later than 30 days, of
changes pertaining to billing information. Please submit this information on a W-9 form. Changes to a
Provider’s Tax Identification Number (TIN) and/or address cannot be processed when conveyed via a
claim form. Such changes must be communicated as noted in the Provider Update section of this
manual.
Claims eligible for payment must meet the following requirements:
•
The inmate was incarcerated on the date of service
•
Referral and Prior Authorization processes were followed, if applicable
Paper claims must be submitted on standard CMS1500 (HCFA) and CMS1450 (UB04) red claim forms.
Claims must be printed in Flint OCR Red, J6983 (or exact match) ink, and paper claim forms submitted
must be typed or printed with either 10 or 12 Times New Roman font. Photo copies and faxes of claim
forms or claim forms that are handwritten will not be accepted for processing and will be returned and
a notice sent to the Provider requesting resubmission.
Payment for service is contingent upon compliance with referral and prior authorization policies and
procedures, as well as the billing guidelines outlined in this manual and the Provider Billing Guide

Billing the Inmate
Inmates cannot be billed directly for any service or co-pay.

Clean Claim Definition
A clean claim is defined as a claim received by CENTURION OF FL for adjudication, in a nationally
accepted format in compliance with standard coding guidelines and which requires no further
information, adjustment, or alteration by the provider of services in order to be processed by
CENTURION OF FL. The following exceptions apply to this definition: (a) a claim for which fraud is
suspected; and (b) a claim for which a Third Party Resource should be responsible.

Non-Clean Claim Definition
A non-clean claim is defined as a submitted claim that requires further investigation or development
beyond the information contained in the claim. The errors or omissions in the claim may result in: (a) a
request for additional information from the Provider or other external sources to resolve or correct
data omitted from the claim; (b) the need for review of additional medical records; or (c) the need for
other information necessary to resolve discrepancies. In addition, non-clean claims may involve issues
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regarding Medical Necessity and include claims not submitted with the filing deadlines.

Timely Filing
Contracted Providers (in Network) must submit all original claims (first time claims) and
encounters within 120 calendar days from the date of service.
Non-Contracted Providers (out of Network) must submit all original claims (first time claims)
and encounters within 365 calendar days from the date of service.
The filing limit may be extended where the eligibility has been retroactively received by CENTURION
OF FL, up to a maximum of 365 calendar days.
All corrected claims, requests for reconsideration, or claim disputes must be received within
120 calendar days from the date of notification of payment or denial is issued. Reference to
the original claim number should be included in field 22 of the CMS1500 and field 64 of the
UB04 on the resubmitted claim form.

Electronic Claims Submission
Emdeon Payer ID - 42140

Network Providers are encouraged to participate in CENTURION OF FL’s Electronic Claims/Encounter
Filing Program. CENTURION OF FL has the capability to receive an ANSI X12N 837 professional,
institution, or encounter transaction. In addition, it has the ability to generate an ANSI X12N 835
electronic remittance advice known as an Explanation of Payment (EOP). Electronic 835s are delivered
through Payspan. For more information on electronic filing please call (800) 225-2573 Ext. 25525 or
314-505-6525.
Providers that bill electronically are responsible for filing claims within the same filing deadlines as
Providers filing paper claims. Providers that bill electronically must monitor their error reports and
evidence of payments to ensure all submitted claims and encounters appear on the reports. Providers
are responsible for correcting any errors and resubmitting the affiliated claims.

Paper Claims Submission
All paper claims and encounters should be submitted as follows:
Mailing address for Paper Claims:
CENTURION OF FL
PO Box 4090
Farmington, MO 63640-4198
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Timely Filing
Claims should be submitted within 120 days from date of service for consideration. Providers should
expect payment within 30 days after receipt of a clean claim.

General Claim Inquiries
Please call 1-844-243-0795.

Provider Portal
CENTURION OF FL has a Provider Portal available through which Providers can submit claims, check the
status of claims and/or check eligibility. Please go to www.centurionmanagedcare.com and click on the
“Provider Login” button to request access.

Unsatisfactory or Claim Payment Concerns
If a Provider has a question or is not satisfied with the information they have received related to
a claim, there are effective ways in which a Provider can contact CENTURION OF FL program:
1.
2.
3.
4.

Submit a Corrected Claim
Submit a “Request for Reconsideration”
Contact a CENTURION OF FL Provider Relations Representative at 1-844-243-0795.
Submit a Claim Dispute.

All disputed claims will be processed in compliance with the claims payment resolution procedure as
described in the Provider Complaints section of this manual.
In addition, for Providers who are currently set up for Payspan with another Centene or Centurion plan,
auto-enrollment for receipt of EFT/ERA payments will be available. This is our preferred method of
payment. Providers who would be new to Payspan should contact Payspan at 1-877-331-7154 to get
registered for EFT/ERA, if desired. Any Provider who does not choose to sign up with Payspan will
receive paper checks and Explanations of Payment from Emdeon.

Provider Relations Assistance
Providers may seek assistance through our regional office staff at 1-844-243-0795.

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Provider Updates
To ensure that we can communicate with you effectively, and to avoid any possible delay in claim
payment, it is important that you notify us, in writing, as soon as you are aware of any of the following
situations:
Addition or termination of an office location.
Addition, change, or termination of Tax Identification Number (W-9 required).
Name change (W-9 may be required).
Change in ownership.
Change in a phone number, fax, or e-mail address.
Change in office hours, panel capacity, or age limitation

Provider Complaints
Providers have the right to initiate a formal complaint regarding dissatisfaction with CENTURION OF FL
administrative policy or process. Please contact our regional office at 1-844-243-0795 and ask to speak
with the Vice President of Operations who can help you process your concern.
Complaints about adverse decisions for medical services and or procedures will be reviewed by the
CENTURION OF FL Statewide Medical Director or the appropriate qualified medical professional(s).
Provider complaints related to a medical management decision, including expressing dissatisfaction with
a decision, will be handled at time of receipt. Please call the statewide medical director at 1-844-2430795 to discuss your concern.

CENTURION OF FL Pharmacy Program
CENTURION OF FL will facilitate the administration of prescription drugs for FDOC inmates that are
ordered as part of their on-site treatment plan. FDOC utilizes a formulary for provision of FDOC
healthcare services. Providers are encouraged to use the approved formulary. Please contact the
CENTURION OF FL Regional Office for a copy of the current formulary. When making recommendations
for medications as part of the inmate patient’s treatment plan, we ask that providers be knowledgeable
and understanding that medications that can be easily abused or offer ‘benefits’ from the inmate
standpoint, i.e., abusable narcotics, (inmate can get a ‘high’ from them) can only be recommended
when the provider feels that the medication is the most medically appropriate. If medications are
recommended in your treatment plan that are not on the current CENTURION OF FL/FDOC formulary,
the on-site practitioner will review the request and obtaining the recommended medication will require
the on-site practitioner to obtain non-formulary approval. So, again, it is important to familiarize
yourself and any other treating staff with the formulary.
Our on-site healthcare staff is responsible for ordering, managing and administering all medications
ordered for inmates in the institution. Since on-site medications are obtained through the FDOC
pharmacy, it is not necessary for off-site providers to send an extended supply of medication back to the
correctional facility with an inmate.

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Pharmacy and Therapeutics (P&T) Committee
The CENTURION OF FL P&T Committee continually evaluates the therapeutic classes included on the
formulary. The committee is composed of the CENTURION OF FL Statewide Medical Director, Pharmacy
Program Director, FDOC Clinical Director and CENTURION OF FL site Medical Director(s) and other
appropriate medical professionals. The primary purpose of the committee is to assist in developing and
monitoring the CENTURION OF FL formulary and to establish programs and procedures that promote
the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least
quarterly.

Medical Records
Overview
CENTURION OF FL Providers must keep accurate and complete medical records that comply with all
statutory and regulatory requirements. CENTURION OF FL primary care providers maintain medical
records for all inmates. Timely and complete provision of care information specific to inmate patient
services allows CENTURION OF FL on-site medical practitioners to make informed care decisions and
maintain continuity of care. Also, maintenance of records by you as the Provider will enable provision
of quality healthcare service to FDOC inmate patients. Specialty providers are expected to provide
copies of records of services provided by the specialist for inclusion in the inmate comprehensive
medical record maintained at the prison site.
CENTURION OF FL uses Provider medical record information as an avenue to review the quality and
appropriateness of the services rendered. Provision of privacy and confidentiality of records for care
provided to inmate patients is no different than the requirements for any patient you provide services
for in the community. Florida administrative regulations require Providers to maintain all records for
at least 5 years after the date of medical services for which claims are made, or the date services were
prescribed. Specialty physician will not provide copies of medical records to inmates. If an inmate
requests a copy of his medical record the specialists should refer the inmate to the Health Services
Administrator at the prison.

Release of Medical Records
All inmate patient medical records shall be confidential, and shall not be released without written
authorization. All requests for medical records should be referred the Health Service Administrator at
the prison. Inmates cannot be provided copies or originals of medical records information by any
treating Provider or Facility. FDOC policy for acquiring medical records must be followed.

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Medical Records Audits
CENTURION OF FL routinely audits medical records maintained at the prisons including documentation
provided by specialists and hospitals. CENTURION OF FL may contact providers if the audit results raise
questions about medical documentation provided by the specialist or hospital.

CENTURION OF FL Medical Management Department
Overview and Medical Necessity
The CENTURION OF FL Medical Management Department hours of operation are Monday through
Friday (excluding holidays) from 8:00 a.m. to 5:00 p.m. Authorization may be requested via telephone
or fax.
For telephone authorizations during business hours, the Provider should contact:
Prior Authorization – 1-844-243-0795
Inpatient Concurrent Review – 1-844-243-0795
The CENTURION OF FL Utilization Management (UM) Program is designed to ensure inmates receive
access to the right care, at the right place, and at the right time. Our program is comprehensive in scope
to ensure services provided are medically necessary, appropriate to the inmate’s condition, rendered in
the most appropriate setting, timely, and meet nationally recognized standards of care.

CENTURION OF FL’s UM Program includes:
•
•
•
•
•
•

Prior Authorization
Concurrent Review
Retrospective Review
Discharge Coordination
Complex Case Management
Assistance with Complex Medical Release Cases

Our medical management program goals include:
•
•
•
•
•

Healthcare based on evidence-based guidelines/practice
Monitoring utilization patterns to guard against over or under utilization
Development and distribution of clinical practice guidelines to Providers to promote improved
clinical outcomes and satisfaction
Identification and provision of intensive care and/or disease management for inmates at risk or
with complex care needs
Education of Providers to promote improved clinical outcomes

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Coordination of care with sites to ensure implementation of programs that encourage
preventive services and proactive management of chronic condition and focus on selfmanagement
Focus on early identification and management of inmates with complex care needs
Creation of partnerships with Providers to enhance cooperation and support for
UM program goals.
Coordinated discharge planning program to ensure appropriate utilization of on-site infirmary
and specialized care units in order to minimize hospital length of stays

Prior Authorization Overview
For CENTURION OF FL, the prior authorization process is driven by the on-site Medical Director or
practitioner at the individual correctional facility. The on-site practitioners will initiate all requests for
provision of specialty services to include any additional follow-up care or treatment recommended
based on a specialty provider evaluation or follow-up visit. The on-site practitioner may request
additional clinical input from the specialty provider to document medical need for requested service(s).
CENTURION OF FL considers prior authorization as a request to CENTURION OF FL’s Utilization
Management Department for determination of medical necessity for elective services on the Prior
Authorization List. This process requires completion and approval prior to the service being
scheduled/delivered.
Therefore, an inmate should never automatically be scheduled by the specialty provider for a follow-up
visit. Follow-up appointments and requests for additional services are managed by the on-site Medical
Director and practitioners.
CENTURION OF FL requires Prior Authorization for certain inpatient and outpatient services and
treatments, as well as treatment at CENTURION OF FL Designated Tertiary Facilities or when treated by
Providers practicing in affiliation with those facilities.
Always contact the CENTURION OF FL Medical Management Department if there is any doubt about
whether or not a service requires Prior Authorization or has been already been pre-authorized.

On-Site Practitioner Referral for Specialty Service
CENTURION OF FL’s expectation is that on-site practitioners coordinate all ongoing healthcare services.
CENTURION OF FL requires a referral and prior authorization for all specialty services prior to the service
being scheduled and/or provided if the service is routine or urgent in nature. Prior Authorization
number will be provided by the CENTURION OF FLT clinical scheduling staff at the time of appointment
scheduling if prior authorization is required in order to provide coverage for referrals to all specialists
CENTURION OF FL requires that all specialty providers submit feedback to the referring on-site
CENTURION OF FL practitioner, in writing, that provides the practitioner the outcome of the
examination, tests performed or recommended, and/or any treatment recommendations. Written

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report should include any discussion, education provided directly to the inmate patient regarding
recommendations

Specialist Referral to Specialist for Treatment or Second Opinion
When medically necessary services are beyond the scope of the Specialist’s practice, or, when a
second opinion is requested, the Specialist must collaborate with the CENTURION OF FL on-site
practitioner. The CENTURION OF FL practitioner will be responsible for requesting authorization for
the service.

Process to Request Follow-Up Specialty Services
Specialist should contact the CENTURION OF FL referring on-site practitioner for discussion regarding
additional service recommendations requested during an active appointment. Failure to contact the
referring practitioner and/or CENTURION OF FL utilization management staff for prior authorization of
additional services may result in non-payment of those services

Self-Directed Care
Inmates are not allowed to self-direct care. All services provided must be approved by CENTURION
OF FL. If your office is contacted directly by an inmate, please contact our Medical Management
Department immediately to request clarification of the patient’s eligibility. Inmates, upon release,
are allowed to use any community provider; however, once released from the facility, CENTURION
OF FL will no longer be responsible for cost of services.

Prior Authorization Response Timeline
Routine Prior Authorization Requests:
•
Decisions shall be made within two business days of receipt of all information necessary to
make a decision
•
The requesting practitioner will be called within 24 hours of the decision
•
Written notice of an approval is sent to the practitioner and site Healthcare Services Unit
within two business days of the verbal notification
Expedited Prior Authorization Requests:
•
Decisions will be made as soon as possible taking into account medical urgency and always
within two business days
•
The requesting practitioner will be called within one business day of the decision
•
Written notice of an approval is sent to the practitioner and site Healthcare Services Unit
within two business days of the verbal notification
•
Notification of an adverse determination is sent to the practitioner and site Healthcare Unit
within 24 hours after the decision and no later than 72 hours after the receipt of the
request
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The decision timeframe may be extended if necessary, once, up to 48 hours if
CENTURION OF FL utilization management staff is unable to render a determination
based on lack of information required to complete the review.

Medical Necessity
CENTURION OF FL defines Medical Necessity as healthcare services that are consistent with
generally accepted principles of professional medical practice as determined by whether:
a) The service or level of service is the most appropriate available considering potential
benefits and harms to the inmate patient
b) Service is known to be effective, based on scientific evidence, professional standards and
expert opinion in improving health outcomes
c) For services and interventions not in widespread use, services are based on scientific
evidence and are the least intensive and most cost-effective available.

Review Criteria
CENTURION OF FL has adopted the utilization review criteria developed by McKesson InterQual
Products Specialists representing a national panel from community-based and academic practice, to
determine Medical Necessity for non-emergency inpatient and outpatient services.
InterQual criteria are applied to:
•
Medical and surgical admissions
•
Select outpatient procedures
•
Ancillary services
Criteria are established, periodically evaluated and updated with appropriate involvement from
physicians of Centurion’s Medical Management Services and the Centurion Quality Improvement
Committee. InterQual is utilized as a screening guide and is not intended to be a substitute for
practitioner judgment. Utilization review decisions are made in accordance with currently accepted
medical or healthcare practices, taking into account special circumstances of each case that may require
deviation from the norm in the screening criteria. Criteria are used for the approval of Medical
Necessity, but not for the denial of services. The CENTURION OF FL Statewide Medical Director or
designee is the only individual authorized to make adverse determinations.
Providers may request an appeal related to a Medical Necessity decision made during the authorization
or concurrent review process. The appeal may be submitted at 1-844-243-0795.

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Requirements for Providers to Notify CENTURION OF FL Medical
Management Department
Emergency Services
Prior authorization is not required; however, CENTURION OF FL Medical Management Department
should be notified within one business day of admission to the Emergency Department and/or
subsequent hospitalization secondary to the Emergency Department visit. Notification should include
clinical information related to the emergency services and/or need for hospital admission.

Notification of Observation Stays
It is the responsibility of the receiving hospital and/or Emergency Department to notify CENTURION OF
FL Medical Management Department of all Observation Stays.
Definition of Observation Stay
•

•
•

•
•

If an inmate patient’s clinical symptoms do not meet criteria for an inpatient admission, but
the treating Physician believes that allowing the inmate patient to leave the facility would
likely put the inmate patient at serious risk, he/she may be admitted to the facility for an
Observation Stay. Such stays should be reviewed with the CENTURION OF FL on-site or oncall practitioner or CENTURION OF FL Medical Management Department (Monday through
Friday during business hours) to obtain authorization for inpatient stay and initiate
discharge planning discussions to ensure inmate patient care cannot be managed by an onsite FDOC infirmary
Observation Services are those services furnished on a hospital’s premises, including use of
a bed and periodic monitoring by a hospital’s nurse or other staff
These services are reasonable and necessary to:
o
Evaluate an acutely ill condition
o
Determine the need for a possible inpatient hospital admission
o
Provide aggressive treatment for an acute condition.
Observation stays may last a maximum of 48 hours
If an inmate patient begins treatment in observation status and then transitions to an
inpatient stay, all incurred observation charges and services will be rolled into the acute
inpatient reimbursement rate, or as designated by the contractual arrangement with
CENTURION OF FL. Observation is not separately reimbursed when the stay results in an
inpatient admission.

Concurrent Review
CENTURION OF FL utilization management (UM) staff performs ongoing concurrent review for all
inpatient admissions. CENTURION OF FL UM staff will review the treatment and status of all inmate
patients receiving inpatient services through contact with the hospital’s Care Management Department

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and the attending Physician, when necessary. On-site and telephonic models are utilized to conduct
utilization review in collaboration with the hospital Care Management Department.
An inpatient stay will be reviewed as indicated by the diagnosis and response to treatment. The review
will include evaluation of the current status, proposed plan of care, discharge plan, and any subsequent
diagnostic testing or procedures.
Inpatient concurrent review authorization decisions are made within one calendar day of receipt of
all necessary information and Providers are verbally informed of the decision within one calendar day
of the decision. Written or electronic notification includes the number of days of service approved,
and the next review date.
In the case of a denial of service days:
•
•
•
•

Written notices are sent within one business day of the verbal notification
All existing approved services will be continued without liability to the until the Provider has
been notified of an adverse determination
CENTURION OF FL UM staff will work directly with the hospital’s Care Management Department
to facilitate discharge back to an appropriate FDOC level of care facility
Notices will contain information on how to appeal

Discharge Planning
Discharge planning activities are expected to be initiated upon admission. The CENTURION OF FL UM
staff will coordinate the discharge planning efforts with the hospital’s Care Management Department,
and when necessary, the attending Physician in order to ensure that inmate patient receives appropriate
post-hospital discharge care. It should be noted that FDOC infirmaries can provide a skilled level of
services to inmate patients supporting earlier discharges from the hospital.
Hospital Care Management Departments are encouraged to develop understanding of level of care and
services that can be provided by CENTURION OF FL/FDOC on-site infirmaries. This level of
understanding will assist in promoting coordination of discharge planning with CENTURION OF FL UM
staff.

Retrospective Review
Retrospective review occurs when an initial review of the services provided to an inmate patient occurs
after the date of service. This is sometimes necessary because authorization and/or timely notification
were not obtained prior to the service delivery due to extenuating circumstances.
Routinely this process encompasses services performed by a Provider when there was no opportunity
for concurrent review. However, retrospective review is also performed on active cases where an
appropriate authorization decision cannot be made concurrently within the required timeframe due to

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lack of clinical information. For cases that qualify for a retrospective review, a decision is made within 30
calendar days of receipt of all necessary information.

Summary
The information presented in this Provider Manual is meant to present to Specialty providers and their
staff an overview of coordinating services with CENTURION OF FL. Specific questions should be directed
to CENTURION OF FL Medical Management Department staff.

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