Frequently Asked Questions

Questions

What are Leon Medical Centers hours of operation?

Who do I call for assistance?

What is My Leon Medi Connect and how can I obtain access?

How do I order a new ID card, change my Primary Care Physician (PCP), or order a new Provider & Pharmacy Directory?

How do I obtain a referral?

What is a referral?

Who do I contact if I have a complaint?

What if I'm still not satisfied with the resolution of the complaint?

How do I file an appeal?

What should I do if a drug prescribed to me is not covered?

What drugs are generally not covered?

How can I get copies of my medical records?

What are the rules for changing my PCP?

Can I change my assigned Leon Medical Centers location?

Does the plan provide transportation for my Healthy Living Center appointment?

Does LMCHP provide interpreter services for Healthy Living Center appointments?

How does LMCHP secure the confidentiality of my Protected Health Information?

How does LMCHP evaluate new technology for inclusion as a covered benefit?

Does LMCHP provide incentives for Utilization Management decisions?

Why have an Advance Medical Directive?

What is a Coverage Determination?

How do I request a Coverage Determination?

What is an Organization Determination?

How do I request an Organization Determination?


Answers

What are Leon Medical Centers hours of operation?


Leon Medical Centers hours of operation are Monday – Friday 7am to 5pm, Saturday and Sunday 8am to 2pm at specified Centers.

Who do I call for assistance?


You may call Leon Medical Centers Health Plans (LMCHP) Member Services Department toll free at 1-866-393-5366 or 305-559-5366, from 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays.

What is My Leon Medi Connect and how can I obtain access?


My Leon Medi Connect is an online web portal which offers members personalized and secure on-line access to portions of their medical record. To obtain a user login and password, contact the Leon Medical Centers Customer Service Department at 305-642-5366, Monday – Friday 7am to 5pm, Saturday and Sunday 8am to 2pm.

How do I order a new ID card, change my Primary Care Physician (PCP), or order a new Provider & Pharmacy Directory?


Please call Member Services toll free at 1-866-393-5366 from 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711. You can also make your request online and find the most up to date Provider & Pharmacy Directory on our website: www.lmchealthplans.com.

How do I obtain a referral?


You must coordinate all of your care through your PCP. You will need a referral from PCP to visit a LMCHP specialist. However, you may access the following specialties within the network without a referral from your PCP:

  • Podiatry
  • Chiropractic
  • Gynecology (one well-woman visit annually plus related follow up care)
  • Dermatology
  • Dental
  • Vision (Optician)
  • Hearing
  • Alcohol/substance abuse treatment (benefits through Psych/Care 1-800-221-5487)
        Mental Health (benefits through Psych/Care 1-800-221-5487)

  • What is a referral?


    A referral is a written recommendation from your primary care physician for you to see a specialist or receive needed healthcare services. Your PCP must issue the referral through LMCHP directly prior to your visit. Please discuss with your practitioner the tests and services which are included in the referral. Tests and services, not included in the referral or performed outside the specialist's office, require a separate authorization.

    Who do I contact if I have a complaint?


    If you have an inquiry or complaint about the service you received, your coverage or a provider, you may call Member Services toll free at 1-866-393-5366 from 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711. You may also submit your complaint in writing to the following:

    Leon Medical Centers Health Plans
    Grievance Department
    8600 NW 41st Street, Suite 201
    Doral, Florida 33166

    What if I'm still not satisfied with the resolution of the complaint?


    If you are not satisfied with the resolution of your complaint you may contact Medicare at 1-800-Medicare (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

    How do I file an appeal?


    You may ask for an appeal when you are not satisfied with our initial decision to deny coverage for a prescription drug, item or service you think you should be able to receive. This includes a denial for prescription drug/services you already received or paid for.

    An appeal may be requested within 60 days of the initial coverage decision by calling the Appeals Department toll free at 1-866-959-5366 or 305-631-5348, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711. Appeals may also be submitted via fax to 305-229-7500 or in writing and must be mailed to:

    Leon Medical Center Health Plans
    Appeals Department
    P.O. Box 66-9440
    Miami, FL 33166

    What should I do if a drug prescribed to me is not covered?


    LMCHP carefully selects drugs for coverage based on safety, quality, and effectiveness so that most often the drugs that members will need to take are covered. Sometimes, a drug may be prescribed that is not covered, but LMCHP has a procedure to address these infrequent situations based on medical necessity. Please speak to your physician or call Member Services about making an exception request. You may call Member Services toll free at 1-866-393-5366 from 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays.

    LMCHP evaluates requests for coverage of a non-covered drug based on medical necessity, whenever a request is made through Member Services. A member or the prescribing physician can make the request either by a phone call or in writing. Member services then coordinates with the Utilization Management department where clinical information is gathered and a physician reviewer makes a determination. As always, members can take advantage of the grievance and/or appeals process if they are not satisfied with the determination.

    What drugs are generally not covered?


    In general, the following categories of drugs are either excluded, or have limitations:
  • Appetite suppressants
  • Erectile dysfunction drugs
  • Infertility drugs
  • Drugs used for cosmetic purposes
  • Smoking cessation products
  • Some injectables


  • To obtain further details, call Member Services toll free at 1-866-393-5366 or 305-559-5366, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711.

    How can I get copies of my medical records?


    You should request copies of your medical records from your PCP and your other providers at no cost to you from a Leon Medical Center provider.

    What are the rules for changing my PCP?


    You may change your PCP for any reason, at any time. To change your PCP, call Member Services toll free at 1-866-393-5366 or 305-559-5366, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711.

    Can I change my assigned Leon Medical Centers location?


    Yes, you can change your assigned Center at any time; however, transportation may not be provided if the Center is located outside your geographic transportation coverage area.

    To change your Center, call Member Services toll free at 1-866-393-5366 or 305-559-5366, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays.

    Does the plan provide transportation for my Healthy Living Center appointment?


    Yes, transportation is provided for all scheduled appointment including those for the Healthy Living Centers. Transportation to Healthy Living Centers is only covered when a patient uses the LMC transportation for all their scheduled appointments. Other forms of transportation will not be covered.


    Does LMCHP provide interpreter services for Healthy Living Center appointments?


    No, LMCHP provides interpreter services for medical appointments only.

    How does LMCHP secure the confidentiality of my Protected Health Information?


    LMCHP takes many steps to ensure that your Protected Health Information (PHI) remains confidential. Our routine notifications of your privacy practices includes: our commitment to your privacy; how LMCHP uses and discloses your PHI; other uses and disclosures permitted or required by law; your rights regarding your PHI; how to obtain further information; and how to file a complaint. LMCHP must ask your authorization before disclosing your PHI for non-routine purposes. LMCHP also allows you access to your PHI upon written request. Employees of LMCHP receive education and training to ensure that your written, oral, and electronic PHI is kept confidential. PHI transmitted electronically is encrypted and any documents containing your PHI are stored in a secure area with access limited to designated individuals. LMCHP uses, discloses and requests only the minimum amount of information necessary. LMCHP does not disclose PHI to your employer for employment-related purposes without your authorization, but may disclose PHI for plan administrative purposes. To obtain a complete Privacy Notice outlining all of LMCHP Privacy Practices, call Member Services toll free at 1-866-393-5366 or 305-559-5366, : 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711.

    How does LMCHP evaluate new technology for inclusion as a covered benefit?


    LMCHP reviews new technology to determine their appropriate and safe application. LMCHP reviews literature developed by recognized medical and research groups, government agencies and the Hayes Technology Directory. This information is presented to LMCHP's Utilization Management committee, composed of primary care and specialist physicians, to determine if new technologies should be included in benefit packages. If you have questions on whether a new technology is covered by LMCHP, call Member Services toll free at 1-866-393-5366 or 305-559-5366, : 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711.

    Does LMCHP provide incentives for Utilization Management decisions?


    LMCHP does not use incentives that encourage barriers to care and/or service, or that reward inappropriate restriction of care. Rather, LMCHP encourages appropriate utilization while discouraging any under-utilization. LMCHP affirms that utilization management decision-making is based only on appropriateness of care and services and existence of coverage. LMCHP does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage of service or care. No incentives are offered to encourage decisions that might result in under-utilization.

    Why have an Advance Medical Directive?


    You can plan ahead by writing an Advance Medical Directive, also called an Advance Directive. This statement outlines the medical treatment you would want or names the person you would want to make healthcare decisions for you if you can no longer express your wishes. You can obtain additional information by contacting your Primary Care Physician's office or by calling LMCHP's Member Services toll free at 1-866-393-5366 or 305-559-5366, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711.

    What is a Coverage Determination?


    Any determination (i.e. an approval or denial) made by the Medicare Health Plan to provide or pay for a Part D Drug you believe should be covered.

    How do I request a Coverage Determination?


    You may call our Member services department toll free at 1-866-393-5366 or 305-559-5366, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711. You may also write to us at Leon Medical Centers Health Plans 8600 NW 41st Street, Suite 201 Doral, Florida 33166, or you may fax at (305) 229-7518.

    What is an Organization Determination?


    Any determination (i.e. an approval or denial) made by the Medicare Health Plan to provide or pay for an item or service you believe should be covered.

    How do I request an Organization Determination?


    You may call our Member services department toll free at 1-866-393-5366 or 305-559-5366, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays. For the hearing impaired (TTY), call 711. You may also write to us at Leon Medical Centers Health Plans 8600 NW 41st Street, Suite 201 Doral, Florida 33166, or you may fax at (305) 642-1142.