ANTHEM BLUE CROSS STATE SPONSORED BUSINESS POLICY ...

ANTHEM BLUE CROSS STATE SPONSORED BUSINESS
POLICY AND PROCEDURES
SECTION
Medi-Cal _X_
Policy Number: PNXX_303
Provider Network
Hlthy Fam HMO _X_ Origination Date: 04/30/03
Hlthy Fam EPO ___ Date of Last Review: 03/19/09
SUBJECT
MRMIP ___ AIM _X_ Date of Last Revision: 03/19/09
Dept. Approval Date: 04/21/09
QOC Approval Date: 04/22/09
Provider Termination - Member Notification
(Physicians and Hospitals)
PAGE 1 OF 10
PURPOSE
To ensure a standard process for termination of provider and hospital contracts to include timely
notification to members and providers and to meet regulatory requirements. Additionally, to provide
a mechanism to meet all internal Anthem Blue Cross State Sponsored Business (Anthem)
operational requirements.
POLICY
PROVIDER TERMINATIONS
It is the policy of Anthem to provide at least a 30 days advance notice to members when a contract
with a medical group or individually contracted provider terminates.
Anthem providers are required by their Participating Physician Agreement and/or Group Agreement
to notify Anthem when terminating from the network. For all contracted medical groups, individual
providers and hospitals, written notification is required at least 120 days prior to the termination
date for capitated providers and at least 90 days prior notice for fee-for-service providers.
A Member Notification Letter requires regulatory approval as follows:
• The Department of Managed Health Care (DMHC) must approve all Member Notification
Letters pertaining to terminations of medical groups and hospitals. Member notices cannot be
sent until DMHC has approved the transition filing.
• The Department of Health Care Services (DHCS) must approve all Member Notification Letters
pertaining to terminations of Medi-Cal Managed Care providers, excluding Los Angeles
County, at least 60 days prior to submission.
• LA Care must approve all Member Notification Letters pertaining to terminations of LA County
Medi-Cal Managed Care providers.
• The Major Risk Medical Insurance Board (MRMIB) must approve all templates for Member
Notification Letters pertaining to provider terminations for Healthy Families, AIM or MRMIP
programs.
HOSPITAL TERMINATIONS
For Hospital terminations, Anthem sends notices to members who are assigned to provider who
does not have admitting privileges at other Anthem contracting hospitals, pursuant to the DMHC
agreement of April 16, 2004. It is also the policy of Anthem to submit member transition filings to
the DMHC in accordance with state law, regulations or other regulatory requirements. Member
notices cannot be sent until DMHC has approved the transition filing.
Privileged and Confidential Communication; For Internal Use Only-Do Not Copy or Forward-Proprietary Information

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
DEFINITIONS
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 2 OF 10
“Affected Member(s)” means a member(s) assigned to a terminating medical group or Primary Care
Provider (PCP); members treated by a Specialty Care Practitioner (SCP) within the last 6 months; or
members who reside within a 15-mile radius of a terminating hospital.
“Continued Access to Care/Continuity of Care” means the process of authorizing continuation of
services with a terminating physician, medical group or hospital under specified conditions and for
a limited period of time with a plan of care to transition the member to a network provider.
“Provider Contracting and Database Administration (PCDA)” is the department responsible for
system updates and changes.
“Hospital” means a general acute care hospital.
“Medical Group” means a medical group, independent practice association or any other similar
organization, reimbursed at a fee-for-service (FFS) or capitated per member per month (capitated)
basis.
“Member Notification Letter” means an appropriately approved letter being sent to members
regarding a provider termination.
“Physicians” means Primary Care Providers (PCP) or Specialty Care Providers (SCP) contracted
either individually or through a Medical Group.
“Provider” means an individual physician, medical group or hospital contracted with Anthem to
provide services to Anthem members.
PROCESS
PCDA is responsible for receiving and processing termination notices from providers and tracking
provider terminations internally.
PCDA coordinates efforts with:
• PCDA Reporting conducting impact analysis reports;
• Compliance (regulatory approvals)
• Health Care Management (Hospitals and Capitated Medical Groups)
• Credentialing (terminations for cause)
• Case Management (Continued Access to Care)
• QI/Compliance Analyst (coordination of transition plan and member notification for groups and
hospitals, coordinating the required notification to regulatory agencies, members and other
interested parties)
• PCDA Reporting (member mailing information)
• Network Management and Field Operations (Professional Contracts)

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 3 OF 10
The following information details the procedure and process specific to medical group terminations,
hospital terminations and individual physician terminations.
PROCEDURE
Capitated Medical Group/IPA and Hospital Terminations
Anthem provider agreements 1 require medical groups/IPAs and hospitals to provide Anthem with
written notification of the intent to terminate their agreement at least 120 days prior to the
termination date.
Notification of the intent to terminate either a provider or hospital contract is received by Anthem
Contracting, PCDA and/ or Health Care Management. Notification of the intent to terminate by
Anthem is outline in policy PNXX_008.
• Within 24 hours of receipt of a notice of intent to terminate,
o PCDA notifies Anthem’s Compliance, Reporting, Medical Management, as well as
the QI/Compliance Analyst for FFS medical group (PCP and SCP) terminations.
o Health Care Management notifies the QI/Compliance Analyst, Compliance, Network
Reporting and PCDA of the impending capitated medical group or hospital
termination.
o If the medical group has 2,000 members or more PCDA Reporting will be required
to complete an impact analysis and forward the analysis to the Q/I Compliance
Analyst
o The Q/I Compliance Analyst will prepare a Provider Group Block Transfer Filing
which includes the impact analysis and member notification letter template. The
Filing will be submitted to the Legal department for review.
o Once approval has been obtained from Legal, the Q/I Compliance Analyst will
submit the filing to the DMHC 75 days in advance of the termination date.
o The Q/I Compliance Analyst will also forward the filing to the Compliance
department.
o The Compliance Department will submit the filing to the DHCS.
o If the medical group has less than 2,000 members, the Compliance Department will
send the impact analysis along with the member notification letter template to the
DHCS or LA Care sixty (60) days prior to the termination date for approval.
• PCDA: PCDA identifies the PCPs within a terminating medical group that will be
terminating and submits a request to PDO to close any open PCP panels so that no new
members are assigned to the terminating providers.
• PCDA Reporting: PCDA Reporting conducts an impact analysis of the terminating
provider(s) to assess the availability of alternate providers in Anthem’s network that are
located within the DMHC’s geographic access standards. This impact analysis is used to
complete a group or hospital termination worksheet, which may, in turn, be used to
1 Fee-for-Service Group Agreements, Capitated Medical Group Agreements and Hospital Agreements

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 4 OF 10
prepare an enrollee transfer filing for the DMHC (for medical group terminations). It is
also used to notify regulatory agencies, as necessary or required, of any changes to the
composition of the Anthem network that could materially reduce member’s access to
care.
For hospital terminations, the impact analysis includes an assessment of the availability
of alternate contracting hospitals in the same geographic area, with the same range of
services as the terminating facility. It also includes, among other things, the number of
providers with exclusive admitting privileges at the terminating hospital; the number of
members assigned to providers with exclusive admitting privileges at the terminating
hospital; the number of specialists affiliated with the terminating hospital; the number of
alternate hospitals located in the county; and the percentage of members with and
without access to a hospital within 15 miles. Anthem will verify that the alternate
hospitals comply with the DMHC’s geographic access standards for members. Anthem
will also verify that its contracting physicians/medical groups can admit members to an
alternate hospital that is geographically accessible and has the same range of services as
the terminating hospital.
When a hospital terminates, members are not “block transferred” to another hospital
because Anthem members are not assigned to a particular hospital. Members may
obtain services from any Anthem contracting hospital to which their physician or
medical group maintains admitting privileges. Anthem’s network physicians and
medical groups/IPAs are contractually obligated to admit Anthem members to
contracting hospitals (physicians/medical groups/IPAs are not obligated to admit
members to a particular or designated facility).
In summary, Anthem shall:
A. Provide written notification to the appropriate regulatory agency in compliance with
termination guidelines
B. Submit a full impact analysis to the regulatory agency as to how Anthem will fulfill
the agency’s member access requirements.
C. Notify in writing, all affected members at least and providers of the impending
termination.
D. Ensure that provider and member letters are approved by proper regulatory agency
(DHCS/DMHC/LA CARE) at least 60 days prior to use.
For medical group/IPA terminations, if members will be reassigned to another
contracted medical group (rather than an individually contracting fee for service
physician); Anthem will verify the receiving group’s financial and administrative
capacity to accept the additional membership.

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 5 OF 10
Once the impact analysis is complete, PCDA Reporting submits the analysis to the
QI/Compliance Analyst, PCDA, and Compliance. Additionally, PCDA Reporting
submits the provider information (i.e., PCP numbers, medical group TIN) to PCDA
Reporting and the QI/Compliance Analyst.
For SCP medical group terminations, PCDA Reporting provides the list of impacted
SCPs. The QI/Compliance Analyst requests a claims report from PCDA Reporting that
identifies all of the Anthem members seen by the terminating SCP within the past 6
months.
• PCDA Reporting: For impending terminations, PCDA Reporting identifies all affected
members based on the request (i.e. members located within the selected zip codes,
members assigned to the PCP or members seen by the terminating SCP) and submits the
member mailing information to the QI/Compliance Analyst.
• QI/Compliance Analyst: Once the QI/Compliance Analyst has all required data
elements (worksheets, proposed Member Notification Letter, impact analysis and
affected member mailing list), s/he submits all required information to Anthem Legal at
least 85 days prior to the impending termination. Once Anthem Legal approves the
filing, the QI/Compliance Analyst submits the filing to the DMHC at least 75 days prior
to the impending termination date. The QI/Compliance Analyst notifies Anthem Legal,
PCDA, Contract Manager, Network Management, Medical Management, Operations
and Compliance of approvals and the member notification mailing is sent.
• Compliance. Compliance submits the required information to the QI/Compliance
Analyst and Anthem Legal for filing.
For medical group/IPA terminations, Anthem Legal reviews the DMHC enrollee transfer filing and
sends the filing along with the proposed Member Notification Letter back to the QI/Compliance
Analyst for submission to the DMHC
For hospital terminations, pursuant to the DMHC’s revised position on member
notification and filings for hospital terminations (communicated to Anthem via e-mail on
April 16, 2004), Anthem will send a copy of the impact analysis report and voluntary
Member Notification Letter to the DMHC approximately 60 days prior to the effective
date of termination.
• QI/Compliance Analyst: Once the transition plan and proposed Member Notification
Letter are approved by the DMHC, the QI/Compliance Analyst coordinates the Member
Notification Letter mailing with Product Services & Promotions. The mailing is a joint
effort between PCDA, Product Services & Promotions and Mail Services.
For PCP medical group terminations, the 60 day advance Member Notification Letter
will instruct the member to contact Anthem if they:
o Have any questions or require assistance in selecting a new PCP
o Are pregnant

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 6 OF 10
o Are receiving ongoing treatment from the terminating provider
o Have a child younger than age 3 who is receiving services from the terminating
provider
o Are scheduled for surgery or other procedure
For SCP medical group terminations, the Member Notification Letter instructs the
member to contact his or her PCP as soon as possible in order to receive a referral to a
new specialist. Additionally, the letter instructs the member to contact Anthem if they:
o Have any questions
o Are pregnant
o Are receiving ongoing treatment from the terminating provider
o Have a child younger than age 3 who is receiving services from the terminating
provider
o Are scheduled for surgery or other procedure
In addition, the QI/Compliance Analyst provides PCDA, Operations, Compliance and
Case Management with a copy of the Member Notification Letter and the member
mailing list to identify potential Continued Access to Care/Continuity of Care cases.
• Case Management: Case Management reviews the member mailing list and identifies
any members that may qualify for Continued Access to Care/Continuity of Care. 2
• PCDA: If the member has not selected a new PCP by the termination date, a new PCP
will be assigned to the member. The PCDA is responsible for the actual system
reassignment. The member receives a new membership card identifying their new PCP.
In addition to the new membership card, a notice is provided advising that the
terminating PCP is no longer available. If the member desires a different PCP than the
one assigned, they are instructed to contact the Customer Care Center.
• Field Operations Staff: Network Education Representatives (NER) will forward all
provider termination notices received in the local Community Resource Center office
directly to the QI/Compliance Analyst to ensure appropriate tracking and notification.
The NER will participate in all meetings related to large group or hospital terminations
to ensure coordination of issues at a local level.
• Network Management staff (Professional Contracts): Contract Managers will be
responsible to forward provider termination notices received to the QI/Compliance
Analyst.
2
Refer to Anthem Blue Cross SSB and BCC Corporate Policies and Procedures regarding UM/Transition Assistance and Continuity of
Care/Transition Assistance

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 7 OF 10
Contract Managers will be participate in all meetings related to large group or hospital
terminations to facilitate contracts with alternative primary care and specialty providers.
It is Anthem ’s practice to cease contract negotiations with a terminating medical
group/IPA once the member notification has been sent. However, in the rare event an
agreement is reached with a terminating medical group/IPA after the member notice has
been sent, but within 30 days after the effective date of termination, Anthem will send a
second notice to members (Attachment B) telling them that a new contract has been
agreed upon and advising that if they would like to return to their prior PCP or medical
group/IPA, then they may contact Blue Cross and request the change. Member notices
advise that members may change PCPs or medical groups/IPAs by contacting Blue
Cross.
By the date of termination, all PCDA databases and mainframe systems reflect that the
provider is no longer a participating provider.
DMHC Waiver
When a provider termination is immediate (due to death or illness of a provider; insolvency of a
provider; or Anthem is provided with inadequate advance notice of the termination), Anthem can
request a waiver of the 60 day notice requirement due to exigent circumstances. All previously
outlined steps apply when a waiver is being requested (i.e., impact analysis and submission to
Anthem Legal). The Q/I Compliance Analyst will submit the waiver to Anthem Legal for approval.
Once Legal has approved the waiver request, the Q/I Compliance Analyst will submit the waiver
request to the DMHC for approval.
Tracking and Communication
The QI/Compliance Analyst is responsible for tracking and maintaining all information regarding
the termination. In addition, the QI/Compliance Analyst coordinates with Associate Development
and Training (AD&T) to ensure that Anthem associates are made aware of information surrounding
the terminations.
AD&T provides communications to Anthem associates and provides any necessary training.
Monthly Meetings
The QI/Analyst conducts monthly meetings with all departments to discuss contract terminations;
operational issues, and other critical information related to the provider/hospital termination
process.
Fee-for-Service (FFS) Physician Terminations
Anthem’s contracts with fee-for-service physicians (PCPs and SCPs) require those physicians to
notify Anthem at least 90 days prior to the termination date. Notification of the intent to terminate
is received by PCDA. PCDA coordinates all aspects of the member notification for individual
physician terminations. PCDA identifies the affected members and sends a Member Notification
letter at least 30 days prior to the termination, indicating the effective date of the termination.

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 8 OF 10
If the FFS PCP has membership of 500 or greater, DHCS must be notified sixty (60) days prior to
the termination date. PCDA will notify Reporting to request an impact analysis and prepare the
member notification letters. PCDA will forward the impact analysis and member notification letters
to the Compliance department. Compliance will send the impact analysis and the member
notification letter template to the DHCS for approval.
• Individually Contracting FFS Primary Care Provider Terminations
To assist the member in selecting a new PCP, a Member Notification Letter is sent outlining the
process for selecting a new PCP. Additionally, the letter will instruct the member to contact
Anthem if they:
o Have any questions or require assistance in selecting a new PCP
o Are pregnant
o Are receiving ongoing treatment from the terminating provider
o Have a child younger than age 3 who is receiving services from the terminating provider
o Are scheduled for surgery
If the member has not selected a new PCP by the termination date, a new PCP will be assigned
to the member. The PCDA is responsible for the actual system reassignment. The member
receives a new membership card identifying their new PCP. In addition to the new membership
card, a notice is provided stating that the terminating PCP is no longer available. If the member
desires a different PCP than the one assigned, they are instructed to contact the Customer Care
Center.
By the date of termination, all PCDA databases and mainframe systems reflect that the
physician is not a participating PCP. In addition, PCDA notifies Case Management of the
provider termination and supplies Case Management with the member roster so they can
identify any Continued Access to Care/Continuity of Care cases.
Every effort is made to send the member notification prior to the termination date. If proper
termination notice is not provided to Anthem and advance notification to members cannot be
achieved, Anthem will send Member Notification Letters as soon as practicably possible. PCDA
will terminate the PCP and reassign the members to a new PCP.
• Individually Contracting FFS Specialist (SCP) Terminations
In order to identify Anthem members being treated by a terminating individually contracted
specialist, PCDA requests a claims report from the Anthem Reporting Department that identifies
all of the Anthem members seen by the terminating SCP within the past 6 months.
Once the report has been prepared, PCDA sends an approved Member Notification Letter to
affected members. The letter instructs the member to contact his or her PCP as soon as possible
in order to receive a referral to a new specialist. Additionally, the letter instructs the member to
contact Anthem if they:
o Have any questions
o Are pregnant
o Are receiving ongoing treatment from the terminating provider

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 9 OF 10
o Have a child younger than age 3 who is receiving services from the terminating provider
o Are scheduled for surgery or other procedure
Every effort is made to send the member notification prior to the termination date. However, if
proper termination notice is not provided to Anthem and prior notification to members of the
termination cannot be achieved, Anthem will send the Member Notification Letter as soon as
practicably possible, advising members to contact their PCP or the Customer Care Center for
referral to a contracted specialist. PCDA will then terminate the SCP.
By the date of termination, all PCDA databases and mainframe systems reflect that the physician is
not a participating SCP. In addition, PCDA notifies Case Management of the provider termination
and supplies Case Management with the member roster so they can identify any Continued Access
to Care/Continuity of Care cases.
REFERENCES
Anthem Policy & Procedure UMXX_097 - Transition of Care (and subsequent) Corporate Policy
2.13 and Addendum - Utilization Management/Transition Assistance and Continuity of
Care/Transition Assistance
Anthem Policy & Procedure PNXX_017 - DHCS Notification of Terminations and Resignations
California Assembly Bill 1286/ California Senate Bill 244
Group or Hospital Termination Worksheet
Medi-Cal Managed Care Participating Physician Agreement
Member Notification Letter
MMCD All Plan Letter 06007
Title 22, Sections 53212 & 53852
DHCS GMC Sacramento Contract, Section 8.12.5
DHCS CV/BA Contract, Section 6.9.8
DHCS Stanislaus Contract, Section 6.9.8
DHCS Tulare Contract, Section 6.9.8
LA Care Contract, Article IV, Section 4.02e
LA Care Plan Partner Manual, Section 3.8, Page 6, Notice to Members Regarding Change in
Covered Services
Senate Bill 244, Section 3.B.
Attachments – Sample Letters
Ca_pnxx_303_sample letters.zip
RESPONSIBLE DEPARTMENTS
Anthem PCDA
Compliance
Case Management

SECTION
Medi-Cal _X_
Provider Network
Hlthy Fam HMO _X_
Hlthy Fam EPO ___
MRMIP ___ AIM _X_
SUBJECT
Provider Termination - Member Notification
(Physicians and Hospitals)
Reporting
Corporate Legal
Network Development
Credentialing
Provider Contracting and Database Administration
Policy Number: PNXX_303
QOC Approval Date: 04/22/09
PAGE 10 OF 10