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 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.
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ANTHEM BLUE CROSS STATE SPONSORED BUSINESS POLICY ...

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