• Overview
• Authorization for Service
  • Referral Department
  • Case Management Department
  • Request a HMO Pre-Authorization
  • Request POS or Triple Option Pre-Certification
  • Refer a Member for Complex Case Management
• Claims
  • Medicare Part D Vaccines
  • Submit Paper Claim
• Coding
• Contracting with Florida Health Care Plans
• Credentialing
• Provider Handbook
• Provider Relations
• Referral Guidance
  • Laboratory Orders for all Networks

Overview

To help service our providers, FHCP has departments dedicated to provider services, medical claims, and program management.

Provider Services Department

The Provider Services Department serves as the initial point of contact for various providers who join FHCP's network. Provider Services is responsible for recruiting new community based or employee providers into FHCP's participating provider network, negotiating and preparing contracts for all providers, managing these contracts, and orienting new providers to FHCP's policies and procedures.

The Provider Services Department is also responsible for:

• Maintaining and managing primary care physician panels
• Administering FHCP employee provider benefits.
• Maintaining, updating, and distributing FHCP's list of participating HMO and Option 2 Providers.
• Coordinating network provider communication
• Managing payment of capitated providers
• Performing financial analysis of provider utilization

Medical Claims Department

The Medical Claims Department is responsible for the receipt, processing and payment of all claims submitted by all providers for medical services rendered to FHCP members.

The Medical Claims Department is also responsible for:

• Processing claims for member care
• Entering and processing claims from capitated providers
• Tracking FHCP Medicare members who are admitted to a long-term care facility.

Program Management Department

The Program Management Department is located in FHCP's Holly Hill facility. Program Management staff educate providers and FHCP employees concerning differences between various FHCP benefit plans, when and how co-payments should be applied, and answer questions concerning coverage of various services.

The Program Management Department is also responsible for:

• Conducting audits of Provider claims
• Providing guidance concerning coding of services and diagnoses related to FHCP member care.
• Maintaining the computer claims system benefit categories and associated adjudication rules.
• Auditing of Risk Adjustment data submitted to CMS relating to Medicare Member classifications.