Medication Reconciliation Post-Discharge

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.

Medication Reconciliation Post-Discharge (MRP) Form

Part D – Coverage Determination

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.

Part D – Coverage Determination Form

Ways to Request a Coverage Determination

• Members contact Member Services toll-free at 833-342-7463 (TTY: 711), 7 days a week 8 a.m. to 8 p.m.
• Physicians and Providers contact the Pharmacy Department 305-422-9300 Opt 4, Monday through Friday, 8 a.m. to 6 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 858-357-2614. (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

Request for Prior Authorization of Benefits

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 Medical Management Department:

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

Request for Prior Authorization of Benefits / Services Form

Claim Disputes for Participating Providers

Participating providers may submit a Claim Dispute within one hundred twenty (120) calendar days from the date of the corresponding Remittance Advice. Claim Disputes submitted past one hundred and twenty (120) days from the date of the corresponding Remittance Advice will be considered a late filing and shall be rejected.

Doctors HealthCare Plans, Inc. encourages you to submit your Claim Disputes online using the link: https://www.doctorshcp.com/claim-dispute-form-par/

If you cannot submit your Claim Dispute online, you may use the Claim Dispute Form for Participating Providers. Supporting documentation must include the Remittance Advice and medical records; additional evidence may be required in specific cases.  Incomplete submissions will not be accepted. Please allow sixty (60) days for processing.

You may submit your Claim Dispute to:

Doctors HealthCare Plans. Inc.
Attn.: Provider Inquiry Unit
2020 Ponce de Leon Blvd, PH1
Coral Gables, FL 33134

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.

Bills of Rights

Medicaid Behavioral Health Authorizations Forms:

• Behavioral Health Authorization Request Checklist
• Authorization Request form for CLUBHOUSE SERVICES (H2030)
• Authorization Request form for PSYCHOSOCIAL REHABILATATION SERVICES (H2017)
• Authorization Request form for TARGETED CASE MANAGEMENT SERVICES (T1017)

When completing and submitting the Authorization Request Form (TCM, PSR, or CBH), please remember to include as much information as possible from the Authorization Checklist in order to support the Authorization decision.