Utilization Management

The Florida Health Care Plans Utilization Management Program encompasses the evaluation and determination of coverage for and appropriateness of medical care and behavioral health services. The purpose of the UM Program is to assist the provider in ensuring that eligible members receive the most clinically appropriate care and services in the most efficient manner possible and to enhance consistency in reviewing cases by providing a framework for clinical decision making. Requests are reviewed along with all pertinent documentation for approval or denial based on evidence-based medical necessity criteria. FHCP utilizes Centers for Medicare and Medicaid Medicare Services (CMS) guidelines, MCG (Milliman) Care 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
Central Referrals manages all pre-service and prior authorization requests.

Utilization Review Department: 386-676-7187 or 866-676-7187
Utilization Review manages authorization and continued review for care received while admitted to a hospital, skilled nursing facility, behavioral healthcare facility, or home health care service.

Member Services Department: 386-615-4022 or 877-615-4022
Member Services handles all member complaints, appeals, and grievances.

For FHCP’s Dedicated Case Management Team at ActiveHealth Management please call 855-233-7401
Florida Health Care Plans, in conjunction with ActiveHealth Management, provides free Case Management services to FHCP members who are experiencing difficulty with new or chronic health conditions.

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.