About Your Care

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.

Case Management Coordination of Care

Florida Health Care Plans Coordination of Care Program provides free services to FHCP members who are experiencing difficulty with new or chronic health conditions. This may require navigating healthcare services, assisting with understanding health conditions or the physicians’ treatment plan, and helping to empower you to better manage health conditions through health coaching or linking to available resources specific to the individualized as suitable. The team includes Registered Nurse Care Coordinators and Community Resource Coordinators who recognize that new or chronic illnesses can become overwhelming or difficult to manage for the member, family, or caregiver. The team of experienced professionals will work with you and your physician(s) to help meet your healthcare related goals.

Below are services or resources we provide:

  • Personal 1:1 Register Nurses to assist in management of new and chronic illness
  • Function as a healthcare coach
  • Provide advocacy when coming home from the hospital or skilled facility
  • Help coordinate care with multiple physicians
  • Link you to services available based on criteria through your health plan such as Interactive Health at Home Remote Monitoring, Clinical Pharmacist consult, and Health education classes.
  • Coordinate In Home Nurse Practitioner and Physicians Assistants to evaluate your health care in the comfort of your home
  • Link you to available community services, programs, or resources for financial assistance or support services.

We welcome you to contact us directly or speak with your physician if you feel you may benefit from our services.

FHCP Coordination of Care Department

Phone 386-238-3284 or toll free at 855-205-7293

Hearing impaired may call 711

Monday through Friday between 8:00 A.M. and 5:00 P.M.

Email cmanagement@fhcp.com

Your Rights, Privacy, and Protection

Rights & Responsibilities (English)

Rights & Responsibilities (Spanish)

Women’s Health and Cancer Rights Act Annual Notice

Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy‐related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedemas? Call your Plan Administrator, Florida Health Care Plans at 1- 877 615-4022 for more information.

Newborn and Mothers Health Protection Notice

The Newborn and Mothers Health Protection Act has set rules for group health plans and insurance issuers regarding restrictions to coverage for hospital stays in connection with childbirth. The length of stay may not be limited to less than: 48 hours following a vaginal delivery OR 96 hours following a cesarean section.

Determination of when the hospital stay begins is based on the following:

  • For an in the hospital delivery: The stay begins at the time of the delivery. For multiple births, the stay begins at the time of the last delivery.
  • For a delivery outside the hospital (i.e. birthing center): The stay begins at the time of admission to the hospital. Requiring authorization for the stay is prohibited.

If the attending provider and mother are both in agreement, then an early discharge is permitted.

Group Health Plans may not:

  • Deny eligibility or continued eligibility to enroll or renew coverage to avoid these requirements.
  • Try to encourage the mother to take less by providing payments or rebates.
  • Penalize a provider or provide incentives to a provider in an attempt to induce them to furnish care that is not consistent with these rules.
  • These rules do not mandate hospital stay benefits on a plan that does not provide that coverage.

The group plan is not prohibited from imposing deductibles, coinsurance, or other cost-sharing related to the benefits.

Children’s Health Insurance Program

This is an insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women.

Florida KidCare is the State of Florida’s children’s health insurance program for uninsured children who meet income and eligibility requirements. The 1998 Legislature created Florida KidCare in response to the passage of Title XXI of the Social Security Act in 1997. Florida KidCare provides health insurance to children in families with incomes up to 200 percent of the federal poverty level. Three state agencies and the Florida Healthy Kids Corporation, a non-profit organization, form the Florida KidCare partnership. MediKids, Florida Healthy Kids and Title XXI Children’s Medical Services Managed Care Plan compose the Title XXI Children’s Health Insurance Program (CHIP). CHIP is not an entitlement program and the families pay a monthly family premium of $15 or $20 depending on the family’s income. Florida KidCare also includes Medicaid for children.

Visit www.floridakidcare.org or call 1-888-540-5437 for more information.

Notice of Privacy Practice

The Notice of Privacy Practices (NPP) describes how medical information about you may be used and disclosed and how you can access this information. The NPP is available online at FHCP.com or you can request a hard copy by contacting FHCP Member Services

Estimating Your Costs

FHCP offers an interactive Web site that allows members to enter specific information such as medical service descriptions or the AMA’s CPT code(s) related to the medical service to obtain estimates of service costs. Please note that such estimates are a range of prices based on local market costs. Your individual out of pocket cost related to deductibles, maximum out of pocket limits, co-insurance or copayments are not considered in the estimated costs provided by this tool. It is also important to know that your out of pocket expense between in-network vs. out-of-network benefits can be significant and you may also be responsible for charges by non-participating providers for non-emergency services charges that are above FHCP approved rates. Use of this tool does not constitute FHCP approval or authorization for the service.

For medical service cost estimates, FHCP members may use https://healthcarebluebook.com. For specific estimates, you can contact FHCP’s Cost Estimation Center via email at CEC@fhcp.com or via telephone at (800) 352-9824, ext. 5068.

Estimate Your Costs