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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 Utilization Review 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 MCG (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 Utilization Review Department - 386-676-7187 or 866-676-7187
Member Services Department - 386-615-4022 or 877-615-4022

Case Management Coordination of Care - 386-238-3284 or 855-205-7293

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.

Referrals and Prior Authorizations

It is important to understand the difference between a Referral and a Prior Authorization, and how and when to obtain each one. For more information on differences, with examples of each, please click here.

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