ANTHEM BLUE CROSS STATE SPONSORED BUSINESS POLICY ...

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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
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ANTHEM BLUE CROSS STATE SPONSORED BUSINESS POLICY ...

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