For Providers
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Provider Documents
Availity Access
The Availity Portal offers health care professionals free access to real-time information and confirmation of claims submissions.
At Availity you can submit claims.
Utilization Management
Submit Utilization Management/Prior Authorizations by:
Case Management Authorizations:
If you are a long-term care provider that needs authorization please contact your case manager or call FCC at 1.833.FCC.PLAN Ext. 2
Our Utilization Management (UM) department is dedicated to ensuring that patients receive the right care, at the right time, and in the most effective way possible. You Matter, We Care.
The Utilization Management (UM) Program is designed to oversee and support the delivery of high-quality, personalized care for program participants. It includes a comprehensive range of processes, such as:
- Prior Authorization/Pre-Service Review
- Timeframes for notification are:
- Standard Request: Determination within four (4) calendar days.
- Expedited Request - determination within two (2) calendar days
- Inpatient Services
- Post emergency stabilization, if applicable, for all acute and non-acute inpatient facility admissions, including observations, inpatient hospice, behavioral health, crisis stabilization, detoxification, skilled nursing facility, crisis stabilization and rehabilitation.
- Timeframes for notification is: Within 72 hours of an emergency admission
Examples of Medical Services that Require Prior Authorization
Inpatient Acute Hospital Admissions (Inpatient/Observation)
- Medical
- Surgical
- Behavioral Health
- Notification required within 24 hours of admission or next business day
- Clinical updates required
- Observation stays extending beyond 48 hours
- Substance Abuse Facilities
- Inpatient Services (Detox) SA Treatment
- Statewide Inpatient Psychiatric Program (SIPP)
- Crisis Stabilization
- Residential treatment (MH & SA)
- Partial Hospitalization (PHP)
Elective Admissions
Included but not limited to:
- Initial evaluation for transplant
- Elective Procedures / Surgery
- Long Term Acute Care (LTAC)
- Skilled Nursing Facility
- Radiology Procedures (requiring Inpatient/Observation)
- All bariatric procedures
- All transplant, excluding corneas
- Behavioral Outpatient Treatment.
- Intensive Outpatient Program (IOP)
- Outpatient Electroconvulsive Therapy.
OB Services
- Vaginal
- C-Section
- Induction of labor – if prior to 39 weeks gestation
- Termination of pregnancy
- Scheduled C-Section
- Greater than 7 ultrasounds (vaginal / us)
Home Health Services
- Skilled Nursing
- Physical Therapy
- Occupational Therapy
- Respiratory Therapy
- Speech Therapy
Private Duty Nursing & Personal Care Services (PDN)
- Private Duty Nursing for children age 20 or younger
- Personal Care Services (Home Health Aide) for children age 20 or younger
- Clinical updates required
Intensive Cardiac and Pulmonary Rehabilitation Services
- Inpatient
- Outpatient
Home Infusion / IVT / SQ, IM
- IV Medication
- Hydration
- Injectable medications (Non oncology and Oncology)
Outpatient Therapy (Free standing/ Outpatient hospital)
- Physical Therapy
- Occupation Therapy
- Speech Therapy
- Respiratory Therapy
Prior authorization required after initial evaluation
Prescribed Pediatric Extended Care (PPEC)
- Pediatric Day Care (Medically Fragile Children)
Advanced Imaging (Outpatient)
- CT/CTA
- MRI/MRA
- PET/SPECT
- Nuclear Medicine Studies
Exclusion
Imaging rendered in the following settings do not require prior authorization: Emergency Department, Inpatient Setting, Observation Unit
Durable Medical Equipment (DME & Supplies)
- Augmentative and alternative communicative systems
- Cochlear and auditory brainstem implants
- Other implantable/semi-implantable hearing aids and devices
- Cranial orthotics
- DME repair
- Beds and accessories
- High-frequency chest compression vests
- Negative pressure wound therapy (wound vac)
- Orthotics
- Prosthetics
- Respiratory equipment and supplies
- Continuous glucose monitoring devices and supplies
- Stimulator devices: bone growth, neuromuscular and spinal cord
- Volume control ventilator
- Wheelchairs and scooters
- Noninvasive home ventilators
- Wearable cardiac devices (e.g., LifeVest®)
Outpatient chemotherapy treatment Facility Charge
- Prior authorization if in a clinic or office setting; or if done in an outpatient hospital setting
All cosmetic surgery
- Potentially cosmetic procedures including but not limited to Blepharoplasty, Breast Procedures, Rhinoplasty, Otoplasty, or Panniculectomy
Any Experimental / Investigation
- AHCA Determination
Pain Management (Outpatient)
Sleep Studies
- Facility based only (place CPT codes)
Molecular Diagnostic Testing (DNA and Genetic Testing)
Behavioral Health (Outpatient)
- Psychosocial Rehabilitation (PSR)
- Medicaid In Lieu of Services (ILOS)
- Behavioral Analysis (ABA) – for ages 21 and under.
Prior authorization required after initial evaluation
Pharmacy
CVS Caremark
- Ph (877) 888-8347
- Fax (866) 255 - 7569
Specialty Drugs
- Required for the list of specialty drugs, when delivered in a provider’s office, clinic, outpatient or home setting.
Transportation
- Non-Emergent ground ambulance transport
- Air medical transport
Ride2MD Ph: 1.833.FCC.PLAN - 1.833.322.7526
Dental Procedures
- Those services that fall under the Medical Benefits (Orthognathic Surgery / Anesthesia / Room & Board)
Shingles Vaccines for Enrollees ages 18-49
Pneumonia vaccine for Enrollees ages 18-64
Not required for enrollees ages 65 and older
Vision Services
Individual Psychotherapy
Family Psychotherapy (Without patient)
Family Psychotherapy (With patient)
Group Psychotherapy
- For Code 90837 and Modifier GT
Other Behavioral Services
Electroconvulsive Therapy Physician’s Fees.
Psychological Testing.
Neuropsychological Testing.
Applied Behavioral Analysis (ABA)
Targeted Case Management
Disclosure: This is not a complete list of covered services. Please refer to member / provider handbook. Our Utilization Management Department is available Monday through Friday from 8 am – 6 pm at Phone: 1.833.322.7526, Fax: 305-675-6138, or Provider Portal.
Continuity of Care
New Medicaid members are given a Continuity of Care (COC) period, where Florida Community Care helps transition those who have been seeing non-participating providers to ones within our Florida Community Care network.
How long is the COC period?
120 days
What services are included in COC for new members?
- Any previously prior authorized ongoing course of treatment, with any provider, including a provider who is not participating with Florida Community Care.
- Florida Community Care will provide continuity of care for treatment, with any provider without any form of authorization, including:
- Treatment plan/plan of Care
- Any previously Prior authorized ongoing course of treatment, with any provider, including a non participating provider with Florida Community Care.
Are there services that may continue past the COC period?
Yes. Services that can continue after the COC period for new members include:
- Prenatal and postpartum care – up to the postpartum visit
- Transplant services through the first-year post-transplant
- Oncology (radiation and/or chemotherapy) for the current round of treatment
- Full course of Hepatitis C treatment drugs
Need Help?
Florida Community Care is a Managed Care Plan with a Florida Medicaid Contract.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact FCC. Limitations, co-payments, and/or restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change. Enrollment Broker/Choice Counseling: 1.877.711.3662 — TDD: 1.866.467.4970
FCC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
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