AHCA Form 5000-3549, October 2013 1 Rule Number 59G-6.010, FAC

NFQA HELP INSTRUCTIONS - MONTHLY REPORTING

Once the registration confirmation e-mail is received, Skilled Nursing Facilities shall submit monthly: net

patient revenues, as well as, Medicaid, Private, and Medicare patient days through the online data

collection form found at: http://ahca.myflorida.com/qaf/. Login using the user name and password you

created during registration. Then, click <Login>.

NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

Choose the reporting month/year from the drop down box. Your facility's information is already populated in the dark grey boxes. Please review this information for any discrepancies. Then click <Next>.

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

Quality Assessment Worksheet: Enter the following information.

Monthly net patient revenue: Monthly net patient revenue includes the total of all payer types

(see statute for further definition of Net Patient Revenue). Enter this amount in the Monthly Net Patient Revenue box (NOTE: This field is optional).

Data entry A: Total Medicaid Patient Days: Enter the total number of Medicaid days for the current month based on dates of service paid or payable by Medicaid.

Data entry B: Total Private/Other Non-Medicare Days: Enter the total number of Total Private/Other Non-Medicare Days for the current month based on dates of service paid or payable by any other source that is neither Medicaid nor Medicare.

Data entry F: Total Medicare Patient Days: Enter the number of Medicare patient days for the current month based on dates of service paid or payable by Medicare. Medicare resident days mean those patient days funded by the Medicare program or by a Medicare Advantage or special needs plan.

The system automatically calculates Total Non-Medicare Days (C), Provider Assessment Daily Rate (D), Total Amount Due (E), and Total Patient Days (G). When data entry is complete, click <Next>.

See following page for Screenshot.

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

Facility Quality Assessment

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inputs each facility's daily

assessment rate.

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

Verification Page:

Verify that the monthly data input for your facility is correct. If there is an error click <Previous>, which directs you back to the Assessment Worksheet. There you can correct any errors. Notice the Total Amount Due. This is the amount of your facility's monthly assessment. If all the information is correct click <Submit>.

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

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The remittance document is to be printed and submitted with payment. To go to the Remittance page, either click <Print Invoice Image> for pdf. format or click <Print HTML Invoice> for HTML format.

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Click here to view and print the Remittance Document in HTML.

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

Remittance Document:

If you chose the <Print

HTML Invoice> option

you must click on

<File> and then <Print>

to print the invoice

You may also export

the remittance form

to a pdf. file and save

it to your desktop .

Then print it that way.

Click the printer icon to

print. If you are unable to

print please download the

Microsoft Active X control

software that pops up on

your screen.

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

Remittance Document Continued:

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NFQA HELP INSTRUCTIONS-MONTHLY REPORTING

AHCA Form 5000-3549, October 2013

Rule Number 59G-6.010, FAC

COMPLETE!

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