• Overview
• Grievances (Complaints)
  • Making a Complaint
• Problems/Concerns about Part C Medical Benefits and Coverage
  • Coverage Decisions
  • Appeal a Coverage Decision
• Problems/Concerns about the Part D Prescription Drug Benefit
  • Coverage Decision/Exceptions
  • Appeal a Coverage Decision

COVERAGE DECISIONS

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The Medical Benefits Chart in your Evidence of Coverage lists the services FHCP covers and what you pay for each service. A coverage decision is made when FHCP makes a determination about whether a medical service you receive or a medical service you have received is covered under the plan. You can request FHCP make a coverage decision for you in the following situations:

• You are not getting certain medical care you want, an you believe that this care is covered by our plan.
• You have received and paid for medical care or services that you believe should be covered by the plan and you want to ask our plan to reimburse you for this care.

NOTE: If you disagree when the plan has denied previous requests for medical services or payments this is called an appeal. lf you disagree with the plan reducing or stopping coverage for services you are receiving in a Hospital, Skilled Nursing Facility, Comprehensive Outpatient Rehabilitation Facility or Home Health Care Services this is also called a type of appeal. Refer to the appeal section in your Evidence of Coverage for more information on the appeal process.

How To Ask For A Coverage Decision;

• You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a "fast decision". You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. You can give written permission to someone else to act as your representative. You can utilized the Appointment of Representative form that gives a person legal permission to by your appointed representative. You can also have lawyer act on your behalf.

• To make your request by phone, call 1-877-615-4022. Hearing Impaired call TRS Relay 711. Hour of operation are 7 days a week, 8 a.m. to 8 p.m
• To make your request in writing, by fax or by E-mail contact:
  

  Florida Health Care Plans
  Attn; Member Services
  1340 Ridgewood Avenue
  Holly Hill, FL 32117
  Fax#: 386-676-7149
  E-mail: Member Services click here.

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Generally, we use the standard deadlines for giving you our decision

When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines

A standard decision for a medical service you have not yet received (pre-service) means we will give you an answer within 14 days after we receive your request.

• However, we can take up to 14 more days if you ask for more time, or if we need additional information (such as medical records) that may benefit you. If we decide to take extra days to make the decision we will tell you verbally and in writing.
• If you believe we should not take extra days you can file a "fast complaint/grievance" refer to the complaint section in this website or your Evidence of Coverage in the complaints / grievance section.

If your health requires it, ask us to give you a "fast decision"
A fast decision means we will answer within 72 hours.

• However, we can take up to 14 more days if you ask for more time, or if we need additional information (such as medical records) that may benefit you. If we decide to take extra days to make the decision we will tell you verbally and in writing
• If you believe we should not take extra days you can file a "fast complaint/grievance" refer to the complaint section in this website or your Evidence of Coverage in the complaints / grievance section.

A standard decision about payment for care you have already received can take up to 30 days or more. If you have not received an answer from us within 60 days of your request for payment, you can appeal this decision.

To get a "fast decision" you must meet two requirements:

• You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You can not get a fast decision if your request is about payment for medical care you have already received.)
• You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt you ability to function.

 

• Members of the Medvantage Plan please refer to Chapter 7 of your Evidence of Coverage for complete information on filing a grievance.
• Members of the Medvantage Rx Plan please refer to Chapter 9 of your Evidence of Coveragefor complete information on filing a grievance.
• Members of the Medvantage Rx Plus Plan please refer to Chapter 9 of your Evidence of Coverage for complete information on filing a grievance.

Our Plan Considers Your Request for Medical Care Coverage and We Give You Our Answer. For a "Standard" coverage decision:

• If our answer is "Yes" to part or all of what you requested we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time to make our decision, we will provide the coverage by the end of that extended period.
• If our answer is "No" to part or all of what you requested we will send you a written statement that explains why we said no.

For a "Fast" coverage decision:

• If our answer is "Yes" to part or all of what you requested we must authorize or provide the coverage we have agreed to provide within 72 hours after we received your request. If we extended the time to make our decision, we will provide the coverage by the end of that extended period.
• If our answer is "No" to part or all of what you requested we will send you a written statement that explains why we said no.

If we say no to part or all of what you requested, you decide if you want to make an appeal. For information on making an appeal see the appeal section of this website or your Evidence of Coverage appeal section.

You have received and paid for medical care or services that you believe should be covered by the plan and you want to ask us to reimburse you for this care.

If you pay our plan's share of the cost of your covered services or if you receive a bill, you can ask us for a payment.

Some times when you get medical care you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case you can ask our plan to pay you back. The following are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received:

• When you've received emergency or urgently needed medical care from a provider who is not in our plan's network.
• When a network provider sends you a bill you think you should not pay.

How and where to send us your request for payment.

Send us your request for payment, along with your itemized bill and documentation of any payment you have made.  It’s a good idea to make a copy of your bill and receipts for your own records.


Mail your request for payment together with any bills or receipts to us at:

Florida Health Care Plans
Attn: Claims Department
P.O. Box 9910
Daytona Beach, FL 32120

We will consider you request for payment and say yes or no.

• If we decide that the medical care is covered and you followed all the rules for getting the care we will pay our share of the cost. If you have already paid for the service we will mail your reimbursement of our share of the cost to you.  If you have not paid for the service we will mail the payment directly to the provider.
• If we decide that the medical care is not covered, or you did not follow all the rules we will not pay for our share of the cost. Instead we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.

For detailed information on Part C – Medical Coverage Decisions:

• Members of the Medvantage Plan please refer to Chapters 5 & 7 of your Evidence of Coverage for complete information on requesting a coverage decision.
• Members of the Medvantage RX Plan please refer to Chapters 7 & 9 of your Evidence of Coverage for complete information on filing a grievance.
• Members of the Medvantage RX Plus Plan please refer to Chapters 7 & 9 of your Evidence of Coverage for complete information on filing a grievance.