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 8 OF 10 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
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 9 OF 10 o Have a child younger than age 3 who is receiving services from the terminating provider o Are scheduled for surgery or other procedure Every effort is made to send the member notification prior to the termination date. However, if proper termination notice is not provided to Anthem and prior notification to members of the termination cannot be achieved, Anthem will send the Member Notification Letter as soon as practicably possible, advising members to contact their PCP or the Customer Care Center for referral to a contracted specialist. PCDA will then terminate the SCP. By the date of termination, all PCDA databases and mainframe systems reflect that the physician is not a participating SCP. 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. REFERENCES Anthem Policy & Procedure UMXX_097 - Transition of Care (and subsequent) Corporate Policy 2.13 and Addendum - Utilization Management/Transition Assistance and Continuity of Care/Transition Assistance Anthem Policy & Procedure PNXX_017 - DHCS Notification of Terminations and Resignations California Assembly Bill 1286/ California Senate Bill 244 Group or Hospital Termination Worksheet Medi-Cal Managed Care Participating Physician Agreement Member Notification Letter MMCD All Plan Letter 06007 Title 22, Sections 53212 & 53852 DHCS GMC Sacramento Contract, Section 8.12.5 DHCS CV/BA Contract, Section 6.9.8 DHCS Stanislaus Contract, Section 6.9.8 DHCS Tulare Contract, Section 6.9.8 LA Care Contract, Article IV, Section 4.02e LA Care Plan Partner Manual, Section 3.8, Page 6, Notice to Members Regarding Change in Covered Services Senate Bill 244, Section 3.B. Attachments – Sample Letters Ca_pnxx_303_sample letters.zip RESPONSIBLE DEPARTMENTS Anthem PCDA Compliance Case Management
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