MCC of FL members can request coverage for services by calling Member Services at 1-800-327-8613 (TTY 711). They’ll find out if the service you requested requires prior authorization from a health provider.
- If prior authorization isn’t needed from a health provider for the service, you can call the health provider to schedule an appointment for the service. Member Services can also schedule the appointment for you if you need help.
- If prior authorization is needed from a health provider for the service, the health provider must submit a prior authorization request to MCC of FL’s Utilization Management (UM) department. This must be done before the health provider performs the service. Health providers can call Provider Services at 1-800-327-8613 if they have questions.
- The health provider will receive a decision from MCC of FL’s UM department between 2 -7 calendar days.
If you have any questions, please call Member Services at 1-800-327-8613 (TTY 711).
If you’re not happy with us, your provider or your services for any reason, you or someone you choose can file a complaint. Call us at 1-800-327-8613 (TTY 711).
We will resolve your complaint as soon as we can. If we cannot give you an answer in one day, your complaint will now be a grievance.
A grievance is a formal complaint or a complaint that is not resolved in a day. Call us at 1-800-327-8613 (TTY 711).
We can help you create a grievance. You must call within one year of the issue. We must resolve your issue within 30 days. Our answer will be sent to you in a letter.
If you receive an adverse determination, you can file an appeal. When you file an appeal, you’re asking us to take a second look at our decision. If a service you requested was denied because it didn’t meet the medical necessity criteria, you must submit a clinical appeal. You can request an appeal by calling us at 1-800-327-8613 (TTY 711).
You must file the appeal within 60 days of receiving our decision. If you file the appeal by phone, you must follow up in writing within 10 days.
After we receive your appeal, another person who did not make the original decision, will review the decision. We’ll send you a letter with our final answer within 30 days.
If you need a decision right away, please let us know it is urgent. This occurs when your health is in danger. We will give you an answer within 72 hours. While you wait for our answer, you can continue to receive care. However, if the final decision is not in your favor, you may have to pay for the care. If you need help filing an appeal, please call us toll free at 1-800-327-8613 (TTY 711). We are here Monday through Friday from 8 a.m. to 7 p.m. Eastern time.
You can also get help from: your legal guardian, your authorized representative or your health provider.
Fraud is a false action that is used to gain something of value
Waste is the misuse of services
Abuse refers to overused or unneeded services
Examples of Fraud, Waste and Abuse include:
- Receiving medical services that are not needed
- Billing for services that were not provided
- Billing for services not covered by Medicaid
- Billing twice for the same service
- Using a billing code to get extra payments
- Using another person’s identity to get Medicaid services
- Making false documents by changing:
- The date of service for a claim
- Medical records
- Referral forms
- Paying or taking a bribe
Magellan Complete Care of Florida is dedicated to conducting business in a legal manner. We’re committed to preventing, detecting and reporting fraud, waste and abuse. The Bureau of Medicaid Program Integrity also works to prevent fraud, waste and abuse. They investigate anyone (members, providers and vendors) suspected of trying to commit fraud, waste or abuse against the Medicaid Program. They also:
- Recover overpayments
- Issue warnings
- Send possible fraud cases for investigation
You can report abuse, neglect or exploitation by calling the abuse hotline at 1-800-96-ABUSE.
If you think a provider or someone else is committing fraud, waste or abuse, please report it, along with overpayments and other compliance issues. The Molina Alert Line is available 24 hours a day, seven days a week. An outside company handles the line, and callers do not have to give their names. All reports will be investigated and will remain confidential.
You can also report suspected Florida Medicaid fraud or abuse by contacting:
- The Consumer Complaint Hotline at 1-888-419-3456 or completing and submitting the online Medicaid Fraud and Abuse Complaint Form
- The Florida Department of Financial Services Division of Insurance Fraud (DFS) Hotline at 1-800-378-0445
- The U.S. Department of Health & Human Services Office of Inspector General at
- By e-mail to: HHSTips@oig.hhs.gov
- By mail to:
U.S. Department of Health and Human Services
Office of Inspector General
ATTN: OIG HOTLINE OPERATIONS
PO Box 23489
Washington, DC 20026
Talk to the Attorney General’s Office about keeping your identity confidential and protected.
If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program. The reward may be up to twenty-five percent (25%) of the amount recovered, or a maximum of $500,000 per case (Section 409.9203, Florida Statutes). For more information on reward eligibility through the Attorney General’s Fraud Rewards Program, call toll free 1-866-966-7226 or 1-850-414-3990.
If you have any questions or need help viewing or changing your MCC of FL PCP, please call Member Services at 1-800-327-8613 (TTY 711).
Please carry your MCC of FL member ID card with you at all times. You’ll need it when you visit a MCC of FL health provider.
Please visit our MCC of FL enrollment page to find more info on how to renew your MCC of FL benefits.
Leaving the MCC of FL plan is called disenrolling. You can leave our plan at any time for Good Cause Disenrollment reasons such as:
- You are getting care from a provider that is not part of MCC of FL’s plan but is part of another plan
- If we do not cover a service for moral or religious reasons
- You are an American Indian or Alaskan Native
If the State Agency removes you from the MCC of FL plan for certain reasons, it is called involuntary disenrollment. Involuntary disenrollment can happen for reasons such as:
- You no longer have Medicaid
- You move outside of the MCC of FL service area
- You fake or forge prescriptions
- You knowingly use your Member ID card incorrectly or let someone else use you Member ID card
- You or your caregivers behave in a way that makes it hard for MCC of FL to give you care
You can view Section 8 in the MCC of FL Member Handbook for more information and to find the full list of reasons for disenrollment.
Health assessments help us to understand the type of care you or your child needs. The assessment should take about 15 minutes to complete. If you complete the health risk assessment within 60 days of enrollment, we will mail you a $10 Walmart gift card.
You can complete and submit the health assessment in one of the three ways below:
Type in your answers using the appropriate online form and press submit to complete.
Adult health assessment
Child health assessment (Please complete or have your parent/guardian complete this assessment if you are under 21 years of age.)
2. By Mail:
Download, print, fill out and mail the appropriate health assessment below to MCC of FL:
If you need a printed copy of the health assessment, we’ll send it free of charge. Call Member Services at 1-800-327-8613 (TTY 711) and we’ll send you one.
Mail the completed assessment to:
Magellan Complete Care of Florida
P.O. Box 691029
Orlando, FL 32869
3. By phone:
If you need help or do not have access to a computer, we can help you fill out the assessment by phone. Call MCC of FL’s Member Services at 1-800-327-8613 (TTY 711).
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