Doctors HealthCare Plans, Inc. Your Health, Our Commitment
 2020 Ponce de Leon Blvd, Suite PH 1, Coral Gables, FL 33134   
  

Forms and Online Requests

Please use the links below to download the following forms as PDF files:

Health Risk Assessment (English) / Health Risk Assessment (Spanish)

Doctors HealthCare Plans is focused on providing the right care to  help your patients (our members) stay as healthy as possible. The Health Risk Assessment (HRA) or Health Risk Assessment Tool (HRAT) is used to survey your patients (our members) and obtain information about their health and lifestyle.  We can then use that information to jointly develop personalized care plans.

HRAs should be completed within 90 days of enrollment and must be conducted annually or periodically as needed.  Completed HRAs should be faxed to Doctors HealthCare Plans at (786) 279-8208.

Medication Reconciliation Post-Discharge (MRP) Form

Medication Reconciliation can prevent adverse drug effects events, especially for people with multiple prescription medications and post-discharge.  A potentially negative occurrence can occur if medications are not used and monitored appropriately.

Part D – Physician – Coverage Determination Form

A coverage determination is necessary when a formulary medication requires a Prior Authorization, Step Therapy and/or Quantity Limit.  Exceptions, such as Tiering exceptions and Formulary exceptions, also require coverage determination. A tiering exception is when you believe a member should get a drug at a lower cost share. A formulary exception is when you believe a member needs a drug that is not on the plan’s formulary. All exception requests must be supported by a statement by the prescribing physician.  Standard Coverage Determinations will be made within 72 hours. Expedited Coverage Determinations will be made within 24 hours.

Ways to Request a Coverage Determination

  • CALL: Contact Member Services toll-free at 833-342-7463 (TTY: 711), 7 days a week 8 a.m. to 8 p.m;
  • ONLINE SUBMISSION: Submit your Coverage Determination request online (Coverage Determination request online);
  • FAX: Download and complete a Coverage Determination form and fax the completed form to 866-291-3725. (English / Español);
  • MAIL: Mail the completed request form to the plan’s Pharmacy Department address:

Doctors HealthCare Plans, Inc.
Attn: Pharmacy Department
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134

Provider Compliance Requirements Attestation Form

The Doctors HealthCare Plans, Inc. Provider Compliance Requirements Attestation form is completed by Participating Providers upon conclusion of the online interactive web-based compliance training modules on the CMS Medicare Learning Network (MLN).  Submission of the form attests to the provider’s completion of the General Compliance Training and Fraud, Waste and Abuse training.   Completed forms must be submitted to the Department of Provider Relations for record keeping.

Request for Claim Review Form for participating providers

Claim disputes must be submitted on the Request for Claim Review Form within 120 days from the date of the Remittance Advice. Supporting documentation must include the Remittance Advice; additionally, clinical records, progress reports, CMS Guidelines, etc., may be included. Incomplete forms will be returned to sender.  Allow 60 days for processing.

Please submit the Request for Claim Review Form to:

Doctors HealthCare Plans, Inc.
Attn.: Provider Inquiry Unit
2020 Ponce de Leon Blvd, PH 1
Coral Gables, FL 33134

Waiver of Liability for Non-Participating Providers / Claim Appeals

Please submit claim request in writing together with a Waiver of Liability within 60 days of the Remittance Advice. Supporting documentation may include the Remittance Advice, clinical records, progress reports, CMS Guidelines, etc. Allow 60 days for processing. You may download the Waiver of Liability from: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms.html or (Waiver of Liability)

Please submit the appeal to:

Doctors HealthCare Plans, Inc.
Attn: Grievance & Appeals
2020 Ponce de Leon Blvd, PH 1
Coral Gables, FL 33134

Request for Prior Authorization of Benefits / Services Form

Certain benefits and services require prior authorization.  All informational elements must be completed legibly to the extent required to allow for timely processing.  Please note that CMS defines expedited as those requests where applying the standard timeframe could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.  

Ways to Request a Prior Authorization

  • CALL: For Urgent and emergent requests call Medical Management 305-422-9300, option 1;
  • ONLINE SUBMISSION: Submit your request online (Request for Prior Authorization online);
  • FAX: Download and complete a request form and fax the completed form to 786-578-0291;
  • MAIL: Mail the completed request form to the plan’s Pharmacy Department address:

Doctors HealthCare Plans, Inc.
Attn: Medical Management
2020 Ponce De Leon Blvd., PH 1
Coral Gables, FL 33134

SNP MOC Training Attestation and Evaluation Forms

Providers are required to undergo SNP Model of Care Training. This training provides an overview of SNPs and the responsibilities physicians and other participating health care providers have for their SNP patients.

Bills of Rights

Florida law requires that your healthcare provider or healthcare facility recognize your rights while you are receiving medical care and that you respect the healthcare providers’ or facility’s right to expect certain behavior on the part of patients.

 

 

H4140_PRforms_C
Last Updated: 11/06/2020

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