• Overview
• Authorization for Service
  • Referral Department
  • Case Management Department
  • Request a HMO Pre-Authorization
  • Request POS or Triple Option Pre-Certification
  • Refer a Member for Complex Case Management
• Claims
  • Medicare Part D Vaccines
  • Submit Paper Claim
• Coding
• Contracting with Florida Health Care Plans
• Credentialing
• Provider Handbook
• Provider Relations
• Referral Guidance
  • Laboratory Orders for all Networks

Claims

For questions about claims please contact FHCP at FHCPClaims@fhcp.com.

The following guidelines are to be used by Providers when submitting data to FHCP. It is important that all requested information is included to assure accuracy of the information reported to FHCP. All reported services and diagnoses should be well documented.

1. CMS-1500 forms must include all the information required by Medicare in order to be considered a "clean claim". NPI numbers and referring physician information is required, as applicable.
2. Procedures and services should be reported using the CMS Common Procedure Coding System. In addition, CMS modifiers should be reported when applicable. These codes should be reported using guidelines set forth by CPT, CMS and the AMA.
3. New and established patients are defined below:
   New Patient - Patient has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years
   Established Patient - Patient has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years
4. Claims must include appropriate diagnostic coding for services using ICD-9-CM. These diagnoses should accurately reflect the FHCP member's condition as it relates to the services provided and documented during the encounter. The ICD-9-CM codes should be reported to the furthest level of specificity.
5. When submitting CMS 1500 Forms, the data should be provided to FHCP's Medical Claims Department, Holly Hill facility. Please be sure to submit these claims to FHCP in a timely manner, at least once a week. It is important to provide such data each time you render a service, covered under your contract, to a FHCP member. Special care should be taken to report all services provided.
6. All immunizations should be reported with appropriate CPT codes and the appropriate V code for the diagnosis code.
7. When completing the CMS-1500 form, only one (1) diagnosis reference code should be listed in box # 24E. Only one should be linked to each procedure listed. It is suggested that the diagnosis code that represents the major reason the patient presented for treatment be used.