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) 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
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ANTHEM BLUE CROSS STATE SPONSORED BUSINESS POLICY ...

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