Ultimate Health Plans’ “Provider Manual” was developed for use by contracted Providers and their staff. It is included by reference in the contractual
agreement (the “Agreement”) between Ultimate Health Plans and the Provider, and it is intended to establish guidelines to facilitate compliance with
Ultimate Health Plans’ established policies and procedures. This provider manual contains general information that should be utilized by Providers and
their staff when caring for Ultimate Members.
Provider and Pharmacy Directory
This directory provides a list of our network providers and pharmacies for Citrus, Hernando and Pasco Counties in 2015. Please verify that your
information is accurately listed in our directory so that members may easily find you.
Quick Reference Guide (QRG)
The QRG serves as a handy and valuable resource for information to help serve your patients who have become Ultimate Health Plans’ Members. You can find information on the following topics:
- Frequently Used Contact Information for Ultimate Health Plans
- Pharmacy and Prescription Drugs
- Laboratory Services
- Other Contracted Networks (Vision, Hearing, Dental, Behavioral Health)
- Gym Membership and Locations
- Over-the-Counter (OTC) Benefit
- Case Management
- Prior Authorization
- Grievances and Appeals
- Patient Communication and UHP’s Commitment to Quality Care
Prior Authorization for Medical Care
Prior Authorization List
To view a list of services requiring prior authorization please click on the following link:
Timeframes for Authorization Requests
Ultimate Health Plans processes authorization requests according to the following general time frames, which comply with Medicare guidelines:
- Standard- decision within 14 calendar days from the date of request .
- Expedited- decision within 72 hours from the date of the request (including weekends and holidays). Conditions meeting criteria
for expedited review include an imminent or serious threat to the health of the Member, including, but not limited to, severe pain, potential loss
of life, limb or major bodily function. Please, only submit authorizations for expedited review if you can support that the above criteria applies
to your request.
NOTE: Please ensure that your authorization request includes adequate documentation and/or information to medically support the
request. If the information submitted is not adequate, the determination will be based upon the available information and/or lack of medical
information. To expedite the process and to ensure appropriateness of the decision, it is very important that relevant clinical information be
submitted with the request.
Request for Extensions:
Ultimate may extend the decision time frame up to 14 calendar days. This extension is allowed if the enrollee requests the extension or if the
provider or Ultimate can justify a need for additional information and documents how the delay is in the best interest of the enrollee.
Prescription Drug Information
The Drug List Can Change During the Year
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might
make many kinds of changes to the Drug List. For example, the plan might:
- Add or remove drugs from the Drug List.
- Move a drug to a higher or lower cost-sharing tier.
- Add or remove a restriction on coverage for a drug.
- Replace a brand name drug with a generic drug.
No changes at this time.
Prior Authorization for Prescription Drugs
Request prior authorization for prescription drug that requires it by completing this form on behalf of your patient.
Drug Transition Policy
Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change. We will provide the member with a written
notice after we cover the Transition Supply. This notice will explain the steps they can take to request an exception and how to work with
their doctor to decide if they should switch to an appropriate drug that we cover.
Important news, announcements and helpful information for our participating providers.
Help Honor Your Patients’ Wishes.Our physicians and practitioners should discuss advance directives with their patients (as
appropriate) and file a copy of any advance directive document (e.g., living will, durable power of attorney for health care, health care
proxy or do not resuscitate (DNR) request) in a prominent place within the medical record. Each medical record that contains an advance
directive should clearly indicate that said document is included.
View Ultimate Health Plans Advance Directives Training for Staff and Providers by clicking on the following link
Advance Directives Information for Your Patients
Patient’s Bill of Rights and Responsibilities
Under Florida law health care providers and facilities must recognize patients’ rights while receiving medical care. Providers and facilities also
have a right to expect certain behavior on the part of patients. To access these documents for posting in your office please click on the following links: