Programs & Procedures

Check here for a description of Capital Health Plan programs and company procedures that affect your practice.

Capital Health Plan Medical Policies/Clinical Criteria

• Clinical Criteria

Utilization Management Topics

• Referrals and Authorizations
• Universal Prior Authorization Form
  • Effective 1/1/2017, the Florida Legislature requires all insurers to use the Universal Prior Authorization Form. Therefore, Capital Health Plan will only accept this form when submitted and completely filled out as directed by the instructions. Incomplete forms will not be considered a valid request for services and therefore will not be processed.
• Health Care Decision-Making

Disease Management

• Disease Management Programs

Case Management

• CHP Case Management Program
• Case Management Program Referral Form

Grievances and Appeals

• for Commercial Members Grievance and Appeal Process
• for Medicare Advantage Plus Members
• for Medicare Preferred Advantage Members
• for Medicare Retiree Advantage Members
• Waiver of Liability Statement for Providers

Medicare and Medicaid Fraud and Abuse

• Avoiding Medicare Fraud & Abuse: A Roadmap for New Physicians