Utilization Management

Florida Health Care Plans Utilization Management Program encompasses the evaluation and determination of coverage for, and appropriateness of medical care services, behavioral health services and individual plan coverage benefits, as well as providing assistance to clinicians and members ensuring appropriate use of resources.  

All pre-service and prior authorization requests are managed by the Central Referrals Department.  Care during a hospitalization, Skilled Nursing Facility and Home Health Care are overseen by the Case Management Department.  Member complaints, appeals and grievances are handled by the Member Services Department.  All are reviewed, along with all pertinent documentation for approval or denial based on evidence based medical necessity criteria.  FHCP uses Milliman CareGuide, Centers for Medicare and Medicaid guidelines, and internally developed guidelines to assure the consistency with which medical necessity decisions are made.

Florida Health Care Plans Department Contact information:
Central Referrals Department    -  386-238-3230 or 800-352-9824 and ask for the Referral Department or ext. 3230
Case Management Department  -  386-676-7187 or 866-676-7187
Member Services Department    -  386-615-4022 or 877-615-4022

UM decision making is based only on appropriate care and coverage. Florida Health Care Plans does not reward staff for making denials, and does not use financial incentives that reward underutilization. 

The following applies to FHCP’s Non-Medicare Commercial members:
A Member, a provider the Member has authorized to act on his or her behalf, a State agency, or another person designated by the Member, may submit a Grievance or an Appeal regarding dissatisfaction with a Utilization Management Decision.   The appeal may be submitted to the FHCP Member Services Department.  If the member is not satisfied with the process or answer from FHCP, he/she may submit the appeal to the State of Florida Subscriber Assistance Panel.

The Member must complete the entire Appeal Process and receive a final disposition from FHCP before pursuing review by the Subscriber Assistance Program. The Subscriber Assistance Program will only accept Appeals, it will not accept Grievances.

An Appeal would be submitted to:
Agency for Health Care Administration (AHCA)
Subscriber Assistance Program
2727 Mahan Drive, Building 1
Mail Stop - #26
Tallahassee, Florida 32308
1-888-419-3456
1-850-412-5402

The following applies to FHCP’s Medicare members:
Click here for information on “How to Appeal a Part C Coverage Decision” 
Click here for information on “How to Appeal a Part D Coverage Decision”