Florida Health Care Plans – 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.
A REFERRAL is a Practitioner's "Order" or a Member Request
that facilitates a Member to see another Practitioner (example, a specialist)
for a consultation or a health care service that the referring Practitioner
believes is necessary but is not prepared or qualified to provide. A Referral
Order may be submitted by your Practitioner electronically, by telephone,
or in writing by fax or mail. A Member can request a referral by either
calling his/her Primary Care Physician or calling Member Services.
Direct Access Providers do not require the Member to obtain a Referral
Order. Members that have the Triple Option Rider or Point of Service Rider
do not need a Referral Order to see a specialty practitioner unless requesting
consideration for the service at the lowest FHCP HMO Cost Share.
PRIOR AUTHORIZATION is a "process" of reviewing a Practitioner
Referral Order for certain medical, surgical or behavioral health services
to ensure the medical necessity and appropriateness of the requested care
prior to the health care service being rendered to the Member. The review
process also includes a determination of whether the health care service
being requested is a covered benefit under the Member's benefit plan.
If the requested service is approved, the service is covered under the
benefits defined in the Member’s plan. Members can view their plan
and benefit information at any time in the FHCP Member Portal at www.fhcp.com.
If the requested service is not authorized, the Member and the Practitioner
are notified in writing with the specific reasons for the denial, along
with their Appeal Rights.
DIRECT ACCESS health care services are health care services that do not
require a Member to obtain a Referral Order. Direct Access Providers may
be identified in the FHCP Provider Directory on www.fhcp.com. Members
may call Direct Access Providers to schedule their appointments and care
without obtaining a Referral Order. Examples of Direct Access Services
include: Acute Low Back/Neck Pain Program, Chiropractic Services, Colonoscopy
Screenings, Dermatology Services, Gynecology Services, Hearing Aid Services,
Hospice (for Medicare members; all Non-Medicare Members require Prior
Authorization), Obstetrical Services, Optometry Services, Orthopaedic
Sport Medicine, Pelvic Health Program, Podiatry Services, Smoking Cessation
Program and Weight Management Program.
Thefollowing health care services are examples of services that canbe completed
witha Referral Order fromyour Practitioner and do not require a PriorAuthorization.
- Services provided by FHCPcontracted Allergists, Behavioral Health Providers,
General Surgeons, Hematologists/Oncologists, Rheumatologists, Orthopaedics,
Pain Management Providers, Outpatient Rehabilitation Providers including
Physical, Occupational and Speech Therapists and SleepStudies.
- Durable Medical Equipment, such as, canes, mastectomy bras, oxygen, walkers
The following health services are examples of services that require a Prior
- All inpatient services
- All non-participating providers or facilities in or out of FHCP's
- Braces, Orthotics, Prosthetics
- Breast MRI's
- Cardiac Rehabilitation
- Clinical Trials
- Genetic Testing
- PET Scans when ordered by a Primary Care Provider
- Organ and Bone Marrow Transplants
- Referrals to an Oral Surgeon and Oral Surgery
- Referrals to a Plastic Surgeon or Plastic Surgery
- Surgeries/Procedures that are inpatient, 23-hour Observation, or Outpatient status
- Varicose Vein evaluations and treatment
- Central Florida Regional Hospital for Wound Care
- Certain Medications as identified on the FHCP Formulary, or FHCP policy
as requiring Prior Authorization
- Services that may be investigative or outside the realm of accepted mainstream
For more detailed information, Members can refer to their Certificate of
Coverage/Evidence of Coverage and/or Summary of Benefits Coverage document
from the FHCP Member Portal at
Rev. June 2018