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Health Care Provider Certificate Process

Initial Application

Applications for a health care provider certificate (HCPC) are submitted along with a $1,000 non-refundable application fee.

Initial Review

The review for a HCPC is conducted to assure compliance with Florida Statute and rule. The initial review covers the following areas:

  • Governing Body
  • Medical Records System
  • Quality of Care
  • Quality Assurance Program
  • Referral procedures
  • Internal Risk Management
  • Credentialing
  • Grievance Procedure
  • Provider Network
  • Advance Directives
  • Member Handbooks and/or Subscriber Agreements

If found to be in compliance, the Agency issues a HCPC indicating the counties or parts of counties for which the applicant has been approved.

Renewal

The HCPC is renewed biennially upon submission of an application for renewal with the following checks: $1,000 non-refundable application fee and $300 biennial assessment fee. Upon receipt of an application and checks for renewal, the provider network is reviewed for compliance with Florida Statute and rule.

Monitoring

Ongoing monitoring is accomplished through quarterly and annual grievance reports, annual risk management surveys, complaint information from the HMO Complaint Hotline, and investigations of subscriber quality of care complaints. In addition, HMOs are required to maintain accreditation from a nationally recognized accreditation organization approved by the Agency.

Expansion

An Health Maintenance Organization (HMO) or prepaid health clinic may expand their geographic service area by submitting an expansion affidavit. When the affidavit is reviewed and deemed complete, a review is completed to review the provider network the health plan will use in the expanded area. The affidavit also affirms consistent compliance throughout the expanded network with Florida Statute and rule.

 

Accreditation

Accreditation is a process to measure how a health care organization performs using a nationally recognized set of quality standards. By looking at internal processes of monitoring and evaluating the health care given to members of HMOs, members are assured of quality services rendered in the most cost effective manner. Since 1992, Florida has required HMOs to be accredited by a nationally recognized accreditation organization whose standards have been approved by the Agency.

The following organizations are approved in the state of Florida:

National Committee for Quality Assurance (NCQA)
1100 13th Street NW, Suite 1000
Washington, D.C. 20005
(202)955-3500

Accreditation Association for Ambulatory Health Care (AAAHC)
5250 Old Orchard Road, Suite 200
Skokie, IL 60077
(847)853-6060

American Accreditation HealthCare Commission/URAC
1220 L Street, NW, Suite 400
Washington, D.C. 20005
(202) 216 - 9010