ANTHEM BLUE CROSS STATE SPONSORED BUSINESS POLICY ...

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.