Florida Health Care Plan, Prior Authorization

Florida Health Care Plan, prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• FHCP states that many services do not require prior authorization, but prior authorization is required for certain non-emergency services and for care outside the network/service area depending on plan rules. The provider resource guide says requests are generally submitted through the physician to FHCP Central Referral Department; the prior authorization form instructs providers to fax clinical information, and urgent requests must be called in first. Emergency care does not require prior authorization.
• Exact prior authorization requirements vary by plan, network participation, and service type.
• Official public pages indicate the provider portal contains referral/prior authorization workflows, but the public materials reviewed do not fully enumerate all portal steps.
• The reviewed sources do not provide a single comprehensive public list of all services requiring authorization for every line of business.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3
• Verification resource 4

How to submit prior authorization requests

• Provider Portal electronic submission

• Fax to Central Referral Department

• Phone call for urgent requests

• Mail/other written submission is not clearly specified for initial prior auth in the official sources reviewed

• Submission resource 1

Information commonly required

• Provider order/request for services or supplies
• Patient name and date of birth
• FHCP medical record number
• Requesting provider name and contact details
• Type of referral/request (routine or urgent)
• Diagnosis and ICD-10 code
• Procedure/service details and CPT code when applicable
• Clinical documentation including labs, radiology, pathology, H&P, and provider notes

Turnaround notes and caveats

• Routine medical referral/prior authorization decisions are stated as within 14 calendar days.
• Urgent referrals are stated as 24-72 hours for a decision.
• A member handbook also states pre-service claim determinations not involving urgent care are within 14 calendar days and may extend to 28 calendar days if additional information is needed.
• Exact prior authorization requirements vary by plan, network participation, and service type.
• Official public pages indicate the provider portal contains referral/prior authorization workflows, but the public materials reviewed do not fully enumerate all portal steps.
• The reviewed sources do not provide a single comprehensive public list of all services requiring authorization for every line of business.

Provider resources

• Provider Claims (official)
• FHCP Provider Resource Guide (official)
• FHCP Provider Resource Guide (alternate copy) (official)
• Resources, Education & Support (official)
• Prior Authorization Form (official)
• Prior Authorizations FAQ (official)
• Utilization Management (official)

Sources