Prior Authorizations

When do I need Prior Authorization?

• Members can call and make appointments without a doctor's referral for:
  • Chiropractic
  • Dermatology
  • Podiatry
  • OB/GYN
  • Optometry
• Prior Authorization is needed when a service or procedure falls outside your plan guidelines. Prior Authorization is also needed for you to see a physician outside the network of doctors that participate in your plan.
• Additionally, a drug that is not on the formulary for your plan also requires prior authorization from Florida Health Care Plans.

How can I attain a Prior Authorization?

• Your physician must request start the authorization on your behalf through our Central Referral Department.
• If your Provider has a question on how to initiate the process, they should contact the Central Referral Department at 1-800-352-9824 Ext. 3230.
• A member can request a referral by either calling his/her Primary Care Provider or by calling Member Services Department at 1-800-352-9824.

How long does it take to get a Prior Authorization and how can I see the progress?

• For a routine medical referral, Florida Health Care Plans will respond within 14 calendar days to approve, deny, or pend a request for authorization.
• For an urgent referral, (def.: a serious jeopardy to life, health or maximum function or the ability to regain maximum function) FHCP will respond within 24-72 hours to render a decision.
• Certain medications also require prior authorization; response times in these cases may vary from 24 to 72 hours or 14 calendar days.
• You may view the progress of your authorization from your Member Portal Account under MY BENEFIT PLAN and click on Referrals and Authorizations. You may also call the Member Services Department at 1-800-352-9824 for assistance.

How do I determine when I need Prior Authorization for a medication?

• The Formulary for your plan is in your Member Portal Account under MY PHARMACY Formulary.
• If the medication is not on your Formulary, your provider can submit an authorization for this medication.
• If you need more information, please call the Member Services department at 1-800-352-9824.

What can I do if I am denied a referral that required Prior Authorization?

• If your referral is denied, both you and your provider are notified in writing with the specific reasons for the denial. Both you and/or your provider may request an appeal of FHCP’s decision.
• The steps for filing an appeal will be included in the communication packet you receive.