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Commercial Formulary

Federal Exchange Formulary

Flagler Hospital Employee Health Plan

Parrish Medical Center Employee Health Plan

Announcements

Click Here for the current FHCP Provider Newsletter with news and updates.


Newsletter Archives:

Provider Relations

The FHCP Provider Relations department is available to assist you in resolving issues between your practice and FHCP. Our Provider Relations Coordinator is available to provide on-site training of your staff regarding FHCP Policies and Procedures. The Coordinator will also intervene and resolve coordination of care issues, contract concerns, or supply needed instruction and guidance to you or your staff regarding member care within FHCP's provider network.

The FHCP Provider Relations Department is open Monday-Friday, 9:00 am - 5:00 pm and can be reached as follows:

  • Email Us
  • Call us at (386) 615-4001 or (800) 352-9824, ext. 4001
  • Fax us at (386) 676-7167

Urgent issues after hours or on weekends can be resolved by contacting FHCP's Call Center at (386) 676-7100 or (800) 352-9824.

Provider Education

Provider Handbook

The FHCP Provider Handbook is available for your reference.

To access the document(s) Adobe Reader® must be installed on your computer. If you do not have Adobe Reader ®, you can download it for free by clicking here.

Please be sure to check out the following updates to the handbook:

2017 FHCP Provider Handbook Updates:

Physician’s Drug Guide - FHCP Drug Formulary

Physician’s Drug Guide - Plan Benefit Design

Referrals, Prior Authorizations and Orders

Medicare Transition Documents

Nationally Recognized Criteria

Florida Health Care Plans is licensed to use MCG ( formerly Milliman) Care Guidelines® and CMS Local coverage determinations 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 MCG Guidelines® license includes (1) Inpatient and Surgical Care Guidelines, and (2) General Recovery Guidelines, Skilled Nursing Facility and Home Health Care . 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. 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 MCG Guidelines® are proprietary to MCG and not published on this Internet site.

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.

Request for Review

New information or technology that would be relevant to FHCP to consider when these policies are next reviewed may 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 her ID card.

Prior Authorization List and Form

Claims

Submit a Paper Claim by Mail

FHCP Claims Department
P.O. Box 10348
Daytona Beach, FL 32120-0348 or

  • Claims may also be sent electronically to FHCP via our payer ID number, 59322 or
  • Claims may be entered through Availity at https://apps.availity.com/
  • Questions regarding the submission of claims should be directed to (386) 615-5010

Provider Electronic Payment Options

If you are already enrolled for electronic funds transfer through Florida Health Care Plans, there will be no changes for your payments and the following message will not apply.

Florida Health Care Plans has partnered with VPay to offer an electronic claim payment option for providers using the VPay process. VPay allows your office to receive payments electronically via the MasterCard network. This service will provide a faster and more efficient way for you to receive payment.

Providers accepting VPay will enjoy the following benefits:

  • Quick payments. VPay is delivered primarily via fax so you are receiving payments much quicker than checks.
  • Easy reconciliation. The VPayment and EOB are delivered together in a single document. Enter the card number in your terminal and post the EOB to your billing system and you are done!
  • No bank deposits. Your funds will be delivered electronically to your merchant account.
  • VPay eliminates the risk of fraud and guarantees the delivery of funds to your account, regardless of any fraudulent attempt to process a VCard. No more stolen, lost or whitewashed checks.
  • VPay’s Call Center is staffed with knowledgeable, well trained professionals that can assist with any questions you have about your VPayment.

You do not have to enroll to use VPay. When you receive your VCard, just follow the directions provided on your remittance.

The VPay process also includes an ACH/835 option. You can call the VPay Call Center at (877) 714-3222 to enroll for this service.

We are excited to bring you this safe and efficient electronic method of claims payment. Please keep in mind that you can also check eligibility by registering with Availity at (800) AVAILITY (484-4548). You do not have to file your claims electronically in order to use this valuable service. This service is readily available to you. No more telephone calls!

If you have any questions about this new service, please feel free to contact Steve Berberich, Assistant Administrator of Claims at Florida Health Care Plans. His email address is sberberich@fhcp.com and his telephone number is (386) 615-4085.

Provider Portal and Availty Information

Participating Providers:

All providers participating in FHCP’s networks should use FHCP’s Provider Portal to view FHCP member eligibility, benefits, authorization and claim status information. Member benefit information includes real time accumulator totals for member deductible and maximum out of pocket in comparison with their benefit plan limits. Claim status information includes the stage of the claim in the adjudication process, the amount approved, the amount paid, the member’s cost and date paid.

In addition to these functions, participating providers can view member service history, PCP panel counts, member lab results, and other helpful information and documents related to supporting provider interaction with our members. For example, you can use the Portal to securely upload and send FHCP required claims or authorization documentation, etc. as well as enter and send your claims and authorization requests to FHCP electronically.

Click on the Provider Portal link to register to use this valuable tool. If you have any questions about obtaining access, please call toll free 800-352-9824, ext 7543 or email cec@fhcp.com.

Non-participating Providers:

Availity is used by FHCP to supply non-participating providers with eligibility, benefit, claims and authorization status information. FHCP is included as a health plan choice on Availity’s website. If you have any questions about access, please contact Availity Client Support at 800 / AVAILITY (282-4548) or support@availity.com.

Provider Appeals of Denied Claims:

Information for participating providers

Participating providers may find the reconsideration processes in the FHCP Provider Handbook. The Handbook is available above under the Provider Education section.

Reconsideration requests from participating providers should be submitted electronically via FHCP’s Provider Portal. Supporting documentation can be uploaded securely through the FHCP Provider Portal.

You may also submit your appeal by mail to:

FHCP Claims Department

P.O. Box 10348
Daytona Beach, FL 32120-0348

Information for non-participating providers

Medicare Advantage plans: appeals for nonparticipating providers

In order to request an appeal of a denied claim, you need to submit your request in writing within 60 calendar days from the date of the denial.

Please include with your request:

  • A copy of the original claim
  • The remittance notification showing the denial
  • Any clinical records and other documentation that support your case for reimbursement
  • You need to include a signed Waiver of Liability form holding the enrollee harmless, regardless of the outcome of the appeal.
  • Appeals related to coding edits, clean claim requirements, or payment disputes where there is no member liability do not require a signed Waiver of Liability for FHCP to re-open your claim.

Once you have completed the request, please mail it to:

FHCP Claims Department

P.O. Box 10348
Daytona Beach, FL 32120-0348

Non-Medicare plans: appeals for nonparticipating providers

If you believe the determination of a claim is incorrect, you may file an appeal on behalf of the FHCP member. The appeal will be reviewed by parties not involved in the initial determination. In order to request an appeal, you need to submit your request in writing within the time limits set forth in the Certificate of Coverage if filing on behalf of the covered person.

Please send the appeal to the following address:

FHCP Claims Department
P.O. Box 10348
Daytona Beach, FL 32120-0348

Please include with your request:

  • A copy of the original claim
  • The remittance notification showing the denial or adjustment
  • Any clinical records and other documentation that support your case for reimbursement
  • An Appointment of Representative (AOR) Form or other legal documentation authorizing you to act on the covered person’s behalf (if you are filing an appeal on behalf of the FHCP member)

EDI Guidelines

Companion Guides - ANSI X12N 5010

  • ANSI X12N Implementation Guides for 5010A1 can be obtained from Washington Publishing Company.
  • Companion Guides:
    • ANSI 270/271 - Health Care Eligibility Benefit Inquiry and Response (PDF)
    • ANSI 276/277 - Health Care Claims Status Request and Response (PDF)
    • ANSI 834 - Benefit Enrollment and Maintenance (PDF)
    • ANSI 837 - Professional Health Care Claims (PDF)
    • ANSI 837 - Institutional Health Care Claims (PDF)
    • ANSI 835 -Electronic Remittance Advice (PDF)
      • For 835 Electronic Remittance Advice, Click Here to request a Trading Partner agreement and Electronic Funds Transfer agreement.

Note: This information is being provided for reference and convenience only, and is not intended to grant rights or impose obligations. The information is only intended as a general summary. It is not intended to take the place of laws, regulations, contracts, or other applicable provisions. You are encouraged to review specific laws, regulations, contracts, and other materials as applicable.

If you have any questions about this new service, please feel free to contact Steve Berberich, Assistant Administrator of Claims at Florida Health Care Plans. His email address is sberberich@fhcp.com and his telephone number is (386) 615-4085.