Medical and Clinical Guidelines

Medical Guidelines

Florida Health Care Plans uses medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.

Medical policy does not constitute plan authorization, nor is it an explanation of benefits. Medical policies can be highly technical and complex and are discussed here for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Florida Health Care Plans members should discuss the information in the medical policies with their treating health care professionals.

Medical technology is constantly evolving and these medical policies are subject to change without notice, although Florida Health Care Plans will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional medical policies may be developed from time to time and some may be withdrawn from use. The medical policies generally apply to all of Florida Health Care Plans' fully-insured benefits plans. Additionally, some benefit plans administered by Florida Health Care Plans such as some self-funded employer plans or governmental plans, may not utilize Florida Health Care Plans medical policy. Members should contact the FHCP Member Services Department toll-free at 877-615-4022 for specific coverage information.

The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Florida Health Care Plans has no control or right of control. If you would like to request a hard copy of an individual medical policy, please contact the member's health plan at the number on the back of their identification card.

Clinical UM Guidelines

Florida Health Care Plans is licensed to use Milliman Care Guidelines® to guide utilization management decisions. This may include but is not limited to decisions involving pre-certification, inpatient review, level of care, discharge planning and retrospective review. The Milliman Care Guidelines® licensed include (1) Inpatient and Surgical Care Guidelines, and (2) General Recovery Guidelines. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.
A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits. Clinical UM guidelines can be highly technical and complex and are discussed here for informational purposes. These guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Florida Health Care Plans members should discuss the information in the clinical UM guideline with their treating health care providers. The Milliman Care Guidelines® used by FHCP represent the clinical UM guidelines currently available to all benefit plans offered by FHCP. These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs.

While the Pharmacy guidelines developed by Florida Health Care Plans are published on this web site, the licensed standard  Milliman Care Guidelines® are proprietary to Milliman and not published on this Internet site. Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice. Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use. Members should contact the FHCP Member Services Department for specific coverage information. The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Florida Health Care Plans has no control or right of control. If you would like to request a hard copy of an individual clinical UM guideline or Milliman Care Guideline®, please contact the member's health plan at the number on the back of their identification card.

 

Request for Review

Requests for Pre-Certification or Pre-Service Authorization, or if you have new information or new technology information that would be relevent to FHCP's consideration of these policies when the are next reviewed, should be submitted to:

Florida Health Care Plans

Clinical Services Division

1340 Ridgewood Avenue

Holly Hill, Florida 32117

1 800 352 9824 option 9

Please have your patient refer to the applicable endorsement or rider issued with his or her contract, Evidence of

Coverage, member handbook or certificate of coverage to determine coverage. If your patient is unsure about

particular coverage/benefits or has questions, please have the member call the Member Services number on his or

her ID card.