Member Information

Please contact our Member Services number at 1-833-FC2-PLAN for additional information. (TTY users should call 711). Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

Member Services – Contact Information

CALL 1-833-FC2-PLAN
Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Our automated system is available any time for self-service options. You can also leave a message after hours and on weekends and holidays. Please leave your phone number and the other information requested by our automated system. A representative will return your call by the end of the next business day.

Member Services also has free language interpreter services available for non-English speakers.

TTY 711

Calls to this number are free. Hours are from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

For written correspondence see P.O. Box below:
Florida Complete Care
PO Box 667870
Miami, Florida 33166

How to contact us when you are making an appeal about your medical care

How to file an appeal?

An appeal is the action you or your authorized representative can take if you disagree with a decision Florida Complete Care (HMO I-SNP) Health Plan has made on an Organization Determination.

When we have completed the review, we will provide you, our decision.

There are five successive levels to the appeals process:

Level 1: Reconsideration by the health plan.
Level 2: Review by the Independent Review Entity (IRE)
Level 3: Hearing by an Administrative Law Judge (ALJ)
Level 4: Review by the Medicare Appeals Council (MAC)
Level 5: Review by a Federal District Court.

A decision may be appealed to the next level of appeal when the lower appeal entity issues a decision that is unfavorable to the member. Each unfavorable decision letter will provide instructions on how to move to the next level of appeal.

You or your authorized representative can request a first level appeal by requesting Florida Complete Care plan review an unfavorable organization decision. Reconsideration/appeal requests must be filed with the health plan within 60 calendar days from the date of the notice of the organization determination decision letter. You may file an expedited reconsideration requests orally or in writing. Standard reconsideration requests must be made in writing.

If you or your legal representative requires assistance in preparing and submitting your written Reconsideration request, please contact the Florida Complete Care Member Services department and a Case Manager Assistant (CMA) will assist you.

Once the request is received by Florida Complete Care we will decide and provide notice of our decision as quickly as your health requires, but no later than 72 hours for expedited requests, 30 calendar days for (Pre-Service) standard requests, or 60 calendar days for (Claim denial) requests. If the decision is unfavorable, you or your authorized representative can request further review.

After the first level of appeal, all following levels of appeal will be reviewed by an entity that is contracted with the Medicare Program, or the federal court system. This will help ensure a fair and impartial decision.

By phone:

CALL 1-833-FC2-PLAN

TTY 711

Appeals Requests can be mailed, faxed or emailed to the addresses below:

Florida Complete Care- Appeals
PO Box 668170
Miami, Florida 33166

FAX: 1-800-765-3695

Email: Appeals@FC2healthplan.com

You can also file a complaint at medicare.gov website

Note: You can also use this contact information to follow up on the status of an appeal, or obtain an aggregate number of appeals filed with the plan.

How to contact us when you are making a complaint, which is sometimes called a grievance, about your medical care

How to file a grievance?

What do I do if I have a complaint?

Our members are very important to Florida Complete Care (HMO I-SNP). We work hard to ensure all our members are satisfied with us. If you have any issues, calling our Member Services department is the first step. Member Services will assist you and let you know if you need to do anything else. You can call our Member Services department at 1-833-FC2-PLAN, TTY 711, from 8 a.m. to 8 p.m. seven days a week from Oct. 1 – March 31 and 8 a.m. to 8 p.m. Monday-Friday from April 1 – Sept. 30. If you do not wish to call, you can submit your complaint in writing and send it to us. You may submit your written Grievance request to the Florida Complete Care Grievance & Appeals department at the following address or fax number:

Florida Complete Care – Grievances
PO Box 668800
Miami, Florida 33166
FAX: 1-800-887-2838
Email: Grievance@FC2healthplan.com

You can also file a complaint at medicare.gov website

Note: You can also use this contact information to follow up on the status of a complaint or obtain an aggregate number of grievances filed with the plan.

How to file a grievance?

A Grievance is a complaint or dispute that expresses dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers.

Some examples of why you or your authorized representative might file a grievance include the following:

Benefit design (copays);
Difficulty getting an appointment or having a long wait time for an appointment;
Disrespectful or rude behavior by doctors, nurses, pharmacist or another plan clinic,
hospital staff and plan staff;
Failure to provide you a decision within the required time frame;
Issues/concerns with the services you received;
Issues/concerns with the medical care you received;
If you believe our notices and other written materials are hard to understand.

You may request an expedited grievance if:

We deny your request for an expedited organization/coverage determination;
We deny your request for an expedited reconsideration/Part C appeal and/or redetermination/Part D appeal;
You disagree with our decision to extend the timeframe to make an initial organization or expedited reconsideration/Part C appeal

When filing a written grievance, please provide the following information: Your name, address, member identification number (listed on your Member ID card), your signature or that of your authorized representative, date, summary of the issue, any previous contact with us, and a statement of action requested.

You or your authorized representative may file a grievance with Florida Complete Care orally or in writing no later than 60 days after the occurrence. If you or your authorized representative require help in preparing and submitting your written grievance, please contact the Florida Complete Care Member Services department and a Member Services Representative will help you. Florida Complete Care will notify you or your authorized representative of the decision about your grievance as quickly as your case requires based on your health status, but not later than 30 calendar days after receiving your complaint. In some cases, we may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. We will notify you of our decision about an expedited Grievance within 24 hours.

How to contact us when you are asking for a coverage decision about your medical care

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.

Prior Authorization Forms
Prior Authorization Form – English
Prior Authorization Form – Spanish
Home Health Care Services Prior Authorization Request Form

Below is how to contact us to request a coverage decision.

Coverage Decisions For Medical Care – Contact Information

CALL 1-833-FC2-PLAN

TTY 711

For written correspondence see P.O. Box below:
Florida Complete Care
PO Box 667870
Miami, Florida 33166

Note: You can also use this contact information to follow up on the status of a coverage decision, or obtain an aggregate number of coverage decisions filed with the plan.

References: National Coverage Determinations

Florida Complete Care (FC2) recognizes cultural differences and the influence that race, ethnicity, language and socioeconomic status have on the healthcare experience and health outcomes. We are committed to developing strategies that eliminate health disparities and address gaps in care. Please see the following Resources to Address Cultural Gaps in Care.

Florida Complete Care (FC2) periodically monitors compliance with nationally recognized clinical practice guidelines. Florida Complete Care (FC2) has adopted the following guidelines:

Adult immunizations

Centers for Disease Control and Prevention
Recommended immunization schedule for adults aged 19 years or older, United States 2021

Asthma care

Global Initiative for Asthma (GINA)
2021 GINA Report: Global Strategy for Asthma Management and Prevention

Atherosclerotic cardiovascular disease

American Heart Association (AHA) and the American College of Cardiology Foundation (ACC)
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Diseases: 2011 Update

Back Pain (New for 2020)

Institute for Clinical Systems Improvement
Health Care Guideline: Adult Acute and Subacute Low Back Pain 16th Edition (March 2018)

Breast cancer screening

U.S Preventive Services Task Force (January 2016-an update for this topic is in progress (2021))
Recommendation: Screening for Breast Cancer | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)

Cholesterol treatment

2018 AHA/ACC/American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)/ American Academy of Physician Assistants (AAPA) /Association of Black Cardiologists (ABC) /American College of Preventive Medicine (ACPM) / American Diabetes Association (ADA) / American Geriatric Society (AGS) / American Pharmacist Association (AphA) / American Society of Preventive Cardiology (ASPC) / National Lipid Association (NLA) / Preventive Cardiovascular Nurses Association (PCNA)
https://www.ccjm.org/content/87/4/231

Chronic obstructive pulmonary disease (COPD)

Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (COPD), 2020 Update

Colorectal Cancer Screening Guideline

American Cancer Society Guideline for Colorectal Cancer Screening
Guideline for Colorectal Cancer Screening

Depression

Institute for Clinical Systems Improvement (ICSI): Depression, Adult in Primary Care (March 2016)
Depression, Adult in Primary Care, 17th edition (March 2016)

Diabetes

American Diabetes Association
Standards of Medical Care in Diabetes – 2020

Heart failure

2017 ACC/AHA/Heart Failure Society of America (HFSA) Task Force on Clinical Guidelines
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Heart Risk Calculator

American College of Cardiology Foundation
Heart risk calculator

Hypertension

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Kidney disease

National Kidney Foundation (Note: These guidelines are updated on an ongoing basis by the owning organization) Guidelines and Commentaries – Evidence-based clinical practice guidelines for all stages of chronic kidney disease

Medical records documentation guidelines

Doctor’s HealthCare Plans, Inc. has adopted guidelines based on accreditation and state medical record documentation requirements. Refer to the Doctor’s HealthCare Plans, Inc. provider manual at: https://www.Doctor’s HealthCare Plans, Inc.healthplans.com/Doctor’s HealthCare Plans, Inc.-providers/forms.

Obesity screening in adults

U.S. Preventive Services Task Force
Recommendation: Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)

Opioid Guidelines (New for 2020)

Institute for Clinical Systems Improvement (ICSI)
Pain Assessment, Non-Opioid Treatment Approaches and Opioid Management 8th Edition, August 2017: Version 2
Health and Human Services (HHS)
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics

Preventive care

U.S. Preventive Services Task Force
Recommendation: BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)

Primary Prevention of Cardiovascular Disease and Stroke

American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines
2019 Guideline on the Primary Prevention of Cardiovascular Disease Guideline Made Simple2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (ahajournals.org)

Sickle Cell Anemia (New for 2020)

National Institute for Health (NIH)
Evidenced-Based Management of Sickle Cell Disease: Expert Panel Report 2014

Smoking cessation

Agency for Healthcare Research and Quality
Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice Guideline

Valvular heart disease

AHA/ACC Task Force on Clinical Practice Guidelines
2017 Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease

Well-woman routine care

The American College of Obstetricians and Gynecologists (ACOG)
2021 Recommendations for Well-Woman Care

Quality Programs & Results

Our Quality Improvement Program has goals and activities to make sure our members get the best care possible. We have programs and services to help our members with their individual health needs. Here is some information about how we did in 2022.

Chronic Conditions

Diabetes

This program helps members with diabetes better understand their illness, manage their symptoms, and help them feel healthier. Our Nurse Care Managers work with both the members and their primary care provider (PCP), focusing on goals from your individualized care plan and important screenings. In our first year 2022, 94% of our members with diabetes participated in the program. They received referrals for eye exams, blood sugar monitoring and kidney disease screening. Around 74% of members with diabetes took their statin medication as ordered by their doctor.

Medication Adherence

Medication adherence means following your doctors’ instructions for taking your medications. It is a very important part of managing chronic conditions like high blood pressure, diabetes, and high cholesterol. We work with our members, their caregivers and providers and pharmacies to make sure medications are being used as the doctor ordered. The results in 2022 are very good. Our members with high blood pressure, high cholesterol, or diabetes took their medications as directed between 86 and 90% of the time.

Transitions of Care

Our transitions of care program focuses on supporting members when they leave the hospital or skilled nursing facility. We work with members and their care team to avoid the need to be readmitted to the hospital. In 2023 we are focusing on ensuring timely follow-up care after a medical or behavioral health hospitalization. Seeing your Primary Care Provider or a Mental Health Practitioner after you are discharged is important to stay out of the hospital or emergency room. Only 15% of our members saw a doctor after a hospital discharge and only 7% saw their mental health provider. Our Nurse Care Managers have committed to contacting you within 2 business days of your discharge from a hospital to make sure you have the follow-up appointments you need.

Continuous Quality Improvement

Florida Complete Care’s quality improvement program is based on the principles of continuous quality improvement. Throughout the year, we strive to assess the effectiveness of our programs and measure the impact on members’ health outcomes. We use data and results to continually improve our processes and the delivery of care and services to our members. Check back here for updates on how we did in 2023 and what we are focusing on for 2024.