Terms Used In Florida Statutes 641.495

  • Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
  • Agency: means the Agency for Health Care Administration. See Florida Statutes 641.47
  • Contract: A legal written agreement that becomes binding when signed.
  • Geographic area: means the county or counties, or any portion of a county or counties, within which the health maintenance organization provides or arranges for comprehensive health care services to be available to its subscribers. See Florida Statutes 641.47
  • Grievance: means a written complaint submitted by or on behalf of a subscriber to an organization or a state agency regarding the:
    (a) Availability, coverage for the delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
    (b) Claims payment, handling, or reimbursement for health care services; or
    (c) Matters pertaining to the contractual relationship between a subscriber and an organization. See Florida Statutes 641.47
  • Health care services: means comprehensive health care services, as defined in…. See Florida Statutes 641.47
  • Organization: means any health maintenance organization as defined in…. See Florida Statutes 641.47
  • Provider: means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state. See Florida Statutes 641.47
  • Subscriber: means an individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care services. See Florida Statutes 641.47

(1) The agency shall issue a health care provider certificate to an applicant filing a completed application in conformity with ss. 641.48 and 641.49, upon payment of the prescribed fee, and upon the agency’s being satisfied that the applicant has the ability to provide quality of care consistent with the prevailing professional standards of care and which applicant otherwise meets the requirements of this part.
(2) A certificate, unless sooner suspended or revoked, shall automatically expire 2 years from the date of issuance, or at any time accreditation is withdrawn, unless renewed by the organization. The certificate shall be renewed upon application for renewal and payment of a renewal fee of $1,000, provided that the organization is in compliance with the requirements of this part and all rules adopted under this part. An application for renewal of a certificate shall be made 90 days prior to expiration of the certificate, on forms provided by the agency. The renewal application shall not require the resubmission of any documents previously filed with the agency if such documents have remained valid and unchanged since their original filing.
(3) The organization shall demonstrate its capability to provide health care services in the geographic area that it proposes to service. In addition, each health maintenance organization shall notify the agency of its intent to expand its geographic area at least 60 days prior to the date it plans to begin providing health care services in the new area. Prior to the date the health maintenance organization begins enrolling members in the new area, it must submit a notarized affidavit, signed by two officers of the organization who have the authority to legally bind the organization, to the agency describing and affirming its existing and projected capability to provide health care services to its projected number of subscribers in the new area. The notarized affidavit shall further assure that, 15 days prior to providing health care services in the new area, the health maintenance organization shall be able, through documentation or otherwise, to demonstrate that it shall be capable of providing services to its projected subscribers for at least the first 60 days of operation. If the agency determines that the organization is not capable of providing health care services to its projected number of subscribers in the new area, the agency may issue an order as required under chapter 120 prohibiting the organization from expanding into the new area. In any proceeding under chapter 120, the agency shall have the burden of establishing that the organization is not capable of providing health care services to its projected number of subscribers in the new area.
(4) The organization shall ensure that the health care services it provides to subscribers, including physician services as required by s. 641.19(12)(d) and (e), are accessible to the subscribers, with reasonable promptness, with respect to geographic location, hours of operation, provision of after-hours service, and staffing patterns within generally accepted industry norms for meeting the projected subscriber needs. The health maintenance organization must provide treatment authorization 24 hours a day, 7 days a week. Requests for treatment authorization may not be held pending unless the requesting provider contractually agrees to take a pending or tracking number.
(5) The organization shall exercise reasonable care in assuring that delivered health care services are performed by appropriately licensed providers.
(6) The organization shall have a system for verification and examination of the credentials of each of its providers. The organization shall maintain in a central file the credentials, including a copy of the current Florida license, of each of its physicians.
(7) Every organization shall establish standards and procedures reasonably necessary to provide for the maintenance of a readily accessible medical records system which is adequate to accommodate necessary information including an accurate documentation of all services provided for every enrolled subscriber.
(8) Each organization’s contracts, certificates, and subscriber handbooks shall contain a provision, if applicable, disclosing that, for certain types of described medical procedures, services may be provided by physician assistants, advanced practice registered nurses, or other individuals who are not licensed physicians.
(9) Every organization shall have a subscriber grievance procedure, including, as appropriate, a procedure for disenrolling for cause, which is outlined in all master group and individual contracts as well as in any certificate or handbook provided to subscribers.
(10) The organization shall provide, through contract or otherwise, for periodic review of its medical facilities and services, as required under s. 641.512.
(11) The organization shall designate a medical director who is a physician licensed under chapter 458 or chapter 459.
(12) The provisions of part I of chapter 395 do not apply to a health maintenance organization that, on or before January 1, 1991, provides not more than 10 outpatient holding beds for short-term and hospice-type patients in an ambulatory care facility for its members, provided that such health maintenance organization maintains current accreditation by an accrediting organization whose standards incorporate comparable regulations required by this state.
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