Claims

Submit Claims Electronically

Please Submit Claims Electronically via payer ID 59322
Claims may be entered through Availity at https://apps.availity.com/
If necessary paper claims may also be submitted to PO Box 10348, Daytona Beach, FL 32120-0348
Questions regarding the submission of claims should be directed to (386) 615-5010

Provider Electronic Payment Options

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 855-893-0007 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 service, please feel free to contact Steve Berberich, Administrator of Claims at Florida Health Care Plans. His email address is sberberich@fhcp.com.

Provider Portal Account and Availity Information

Participating Providers:

All providers participating in FHCP’s networks should use FHCP’s Provider Portal Account 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 account 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 Account link to register to use this valuable tool. If you have any questions about obtaining access, please call 386-615-4090, option 4 (account support).

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 Resource Guide. The Guide is available above under the Provider Education section.

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 submitting electronic claims or inquiries, please feel free to contact Steve Berberich, Administrator of Claims at Florida Health Care Plans. His email address is sberberich@fhcp.com.