Long-term Care Diversion Program
Program Documentation and Model Contract
Notices to Contracted Providers
Expansion Applications
Existing Diversion Program MCOs may apply to expand and serve additional counties pursuant to 2.8.4 of the Model Contract. The following required documents must be submitted to your Department contract manager or email them to diversionreports@elderaffairs.org.
- Expansion Request Cover Letter
- Health Care Provider Certificates or Equivalent (HMOs Licensed through Chapter 641, Florida Statutes Only)
- First Page and Signature Page of the Subcontract(s) – 2 for Each Service
- Expanded Benefits (if applicable)
- Subcontractor Attestation (Download)
- Applicable License Verification for Other Qualified Provider
- Geo Access Mapping
A completed Disclosure of Ownership and Control Interest Statement (CMS 1513) is required for all Diversion health plan contractors. Click here to obtain a copy of this form.
Other Documents and Useful Links for Providers
- New MCO Application
- Medicaid Provider Enrollment for New Applicants
- View General Provider Handbooks and Fee Schedules on the Fiscal Agent Information Website.
- 834 Companion Guides
- Sample 834S, 820S and Related Information
- Information for Providers on the Agency for Health Care Administration Website
- Centers for Medicare and Medicaid Services Website
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