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Referrals, Authorizations & 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
2450 Mason Avenue
Daytona Beach, FL 32114

1-800-352-9824 Select 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.

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