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Provider Notices

On April 1, 2018, CMS will start mailing Medicare cards with new Medicare Beneficiary Identifiers (MBIs) to everyone with Medicare. CMS has designated a Provider Ombudsman for the New Medicare Card to serve as an additional resource for the provider community, to learn of implementation problems experienced by clinicians, hospitals, suppliers and other providers. Be ready to use the MBI by April 1 – visit the New Medicare Card website and read CMS’s Fact Sheet.

Provider Manual

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 2018. 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
  • Claims
  • Pharmacy and Prescription Drugs
  • Laboratory Services
  • Other Contracted Networks (Vision, Hearing, Dental, Behavioral Health)
  • Gym Membership and Locations
  • Over-the-Counter (OTC) Benefit
  • Referrals
  • 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.

Our Benefits


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.

Changes to our Formulary (both additions and deletions) are also listed on this website in the following document.

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.

Provider Newsletter

Important news, announcements and helpful information for our participating providers.


Advance Directives

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.

Advance Directives Information for Your Patients


Member 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:


Compliance and FWA Training

As a First Tier Entity, your organization must provide FWA and general compliance training to all your employees and Downstream Entities assigned to provide administrative and/or healthcare services for Ultimate Health Plans. To comply with this requirement, you can use the CMS Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training which you may download by following the instructions below:

Compliance training requirements

Accessing the CMS Training Material

  1. Navigate to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
  2. Scroll to the “Downloads” section
  3. Click on “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training”
  4. Follow the instructions within the CMS document

This page was last modified: 5/1/2018 9:15:48 PM
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Ultimate Health Plans is an HMO plan with a Medicare contract. Enrollment in Ultimate Health Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Medicare beneficiaries may also enroll in Ultimate Health Plans through the CMS Medicare Online Enrollment Center located at www.medicare.gov. Ultimate Health Plans does not collect any member information through this website.


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