Providers

Authorizations

Certain items and services require prior authorization (pre-certification) to evaluate medical necessity and eligibility for coverage. See the current Authorization List to determine if prior authorization is required for general categories of services. See the Authorization List Code Reference companion document for details.

We use both internal and external resources in the authorization process. For the services listed below, the process is handled by the organizations indicated.

Behavioral Health - For all lines of business except Florida Hospital and Rosen TPA plans, authorizations are processed by Magellan Healthcare. Submit requests to Magellan through their website at magellanprovider.com or by calling 1.800.424.HFHP (4347).

Chiropractic Services - Effective 10/1/17, authorizations are processed by Palladian Health for all product lines except Adventist Health System and Rosen Employee Plans. For participating plans, submit requests to Palladian or access clinical guidelines through their website at palladianhealth.com.

Outpatient Therapies (Physical, Occupational, Speech in all settings except home health) - Effective 10/1/17, authorizations are processed by Palladian Health for all product lines except Adventist Health System and Rosen Employee Plans. For participating plans, submit requests to Palladian or access clinical guidelines through their website at palladianhealth.com.

Specialty Imaging, Echocardiograms, Sleep Studies and Positive Airway Pressure (PAP) Devices - Authorizations are processed by AIM Specialty Health (AIM). Submit requests to AIM or access clinical guidelines through their website at: aimspecialtyhealth.com

Spinal Procedures (surgeries, injections) - Effective 10/1/17, authorizations are processed by Palladian Health for all product lines except Adventist Health System and Rosen Employee Plans. For participating plans, submit requests to Palladian or access clinical guidelines through their website at palladianhealth.com.

All Other Authorization Requests – Submit to Florida Hospital Care Advantage by faxing 1.855.328.0059.


Authorization List Documents:


Authorization Request Forms:


Clinical Guidelines:

  • Pharmacy Authorization Criteria (MA-PD) 2018 | 2017
  • Pharmacy Authorization Criteria (MA-PD Employer Groups) 2018 | 2017
  • Pharmacy Authorization Criteria (Commercial - 5 Tier) 2018 | 2017
  • Pharmacy Authorization Criteria (Commercial - 5 Tier - Metal) 2018 | 2017

Other clinical guidelines are available through organizations responsible for administering the authorization process.


For Florida Hospital Employee Plan:


For Rosen Employee Plan:


Last updated: 11/9/17