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
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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