Originating Dept.: Provider Services Date Approved by P&P Committee: March 2004 Originating Dept. Approval: Date: Date:

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1 Title: Notification of Members of Provider Termination Policy No.: PS009_10 Previous Title (if applicable): Supersedes Previous Policy No. (if applicable): PS Department Applicability: Provider Services, Medical Services, Policy Review Frequency: Annual Member Services, Compliance, Information Systems Lines of Business: Medi-Cal, Healthy Families, Healthy Kids, Date Originated: January 2004 Healthy Workers Originating Dept.: Provider Services Date Approved by P&P Committee: March 2004 Originating Dept. Approval: COO Approval: Dept. Approval: CMO/Medical Director Approval: Revision Date(s): 7/2004, 11/2004, 2/2005, 8/2005, 1/2006, 10/2007, 12/2008, 11/2009, 10/2010, 1/2011, 07/2012, 02/2013 CEO Approval: 1. Policy Statement Santa Clara Family Health Plan (SCFHP) provides notification within required timeframes to members of any provider terminations prior to that provider s termination from the Health Plan. This policy is not intended to address SCFHP responsibilities and reporting requirements as specified in Business and Professions Code Section Purpose The purpose of this policy is to comply with Federal and state law by establishing a process whereby providers and SCFHP ensure uninterrupted care for affected members by giving notification to members about provider termination within required timeframes. 3. Definitions A. Termination means the contract between SCFHP and a contracted provider ends, regardless of which party initiates the termination. B. Continuity of care means continuation of covered services when a member s provider terminates while the member is undergoing care for qualifying conditions. C. Contracted Provider ("Provider") means a physician, hospital or IPA participating with SCFHP. Authority: AB 1286, Chapter 591/SB 244, Chapter 590, Statutes of 2003; H & S Code , , , ; DHCS Contract, Exhibit A, Attachment 6, Provision B, Item 10, 11 and 20. Page 1 of 5

2 D. Cause means the contracted provider endangers the health and safety of patients, commits criminal or fraudulent acts, engages in grossly unprofessional conduct, or commits a material breach of their contract. Cause includes issues of medical competence or professional conduct, as specified in CA Business and Professions Code Section 805, et seq, as amended. E. Serious Chronic Condition means a serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. F. Block Transfer means a transfer or redirection of two thousand (2,000) or more enrollees by SCFHP from a terminated Provider Group or terminated hospital to one or more contracting providers that takes place as a result of the termination or non-renewal of a provider contract. G. UM means Utilization Management 4. Procedures Contracting: A. The Contracting Department verifies that termination language in all provider contracts includes but may not be limited to the following: 1. Providers are required contractually to give SCFHP at least a 90-day written notification of termination prior to terminating their contract. 2. SCFHP ensures assigned members are transferred to an appropriate Provider to maintain continuity of care (refer to UM policy entitled Continuity of Member Care After Provider Termination for New and Current Member ). 3. SCFHP works cooperatively with the terminating Provider, as appropriate, during the transfer process. Page 2 of 5

3 B. In the event of an IPA closure after meeting credentialing requirements, the Provider Services Department offers each individual physician within the IPA a direct contract with SCFHP, in an attempt to prevent a disruption to the member s care. C. In the event of a hospital closure or termination--the UM Department determines, and then notifies the Contracting Department if fee-for-service arrangements need to be secured for identified members needing continuity of care. 1. If the Contracting Department receives at least a 90-day written notification, the Compliance Department notifies DMHC 75 days prior to the hospital termination effective date. 2. If the Contracting Department does not receive a 90- day written notification, the Compliance Department notifies DMHC as soon as the termination notice is received and requests a waiver of the 60-day notice to the member because of exigent circumstances. D. If the terminating provider or hospital agrees to continue members care after contract termination, the Contracting Department attempts to negotiate a single-case rate based on: 1. The same contractual terms and conditions that were imposed prior to the contact termination and prior to continuing continuity of care services; or 2. Rates and methods of payment that are the same or similar to rates or methods of payment SCFHP currently uses to pay a contracted provider, including hospitals. E. If the terminating provider or hospital does not agree to the same contractual terms, the Contracting Department notifies the UM Department, which determines whether the members care can be transferred to a contracting provider and what interim arrangements can be made Provider Terminations: F. Medical--All terminations based on quality of care issues are reviewed by SCFHP's Chief Medical Officer/Medical Director, Peer Page 3 of 5

4 Review Committee, and other appropriate persons and review bodies to verify appropriate measures related to patient safety and/or delivery of patient care are taken. The UM Department follows procedures identified in UM policy entitled Provider Medical Dispute Mechanism and Quality policy entitled Peer Review. G. Non-Medical--Upon receipt of a termination notice from the Provider, mutual consent to terminate, or if SCFHP must terminate a Provider for Cause, the Provider Services Department immediately notifies the UM, Member Services, and the Information Systems Departments of the following: 1. Name of the terminated provider or hospital 2. Network affiliation(s) 3. Date of termination 4. Number of affected members by line of business H. The Compliance Department sends an enrollee block transfer document to the Provider Service Department to complete and return, when applicable. If fewer than 2000 members are assigned to an IPA or Provider, a block transfer form does not need to be completed.(refer to Compliance policy entitled Enrollee Block Transfer Notice to DMHC ). I. The Compliance Department submits the completed enrollee block transfer document to DMHC. Member Notification Process: J. Upon notification from Provider Services of Provider s termination, the Member Services Department immediately contacts all affected members. (Refer to Member Services policy entitled Plan Notification to Members of Provider or Hospital Contract Termination.) K. The Member Services Department verifies the affected member s cultural and linguistic needs are met L. The Medical Services Department verifies SCFHP members with Serious Chronic Condition needs are met in the selection of their newly assigned physician, if applicable. Page 4 of 5

5 M. The Medical Services and Member Services Department works to verify affected member(s) continuity of care is undisrupted. (Refer to UM policy entitled Continuity of Member Care After Provider Termination for New and Current Members ) N. This policy is available to members upon request. Provider Reinstates Active Status After Termination: O. If, after notifying members of a provider termination, the provider chooses to remain contracted with SCFHP, Provider Services notifies the Member Services, Medical Services, Compliance and Information Systems Departments P. The Member Services Department immediately sends a written notice to all members, (EXCEPT Kaiser Members) who had been affected by the hospital provider s initial termination. (Refer to Member Services policy entitled Plan Notification to Members of Provider or Hospital Contract Termination ). 5. Confidentiality of Information 1. SCFHP delegates to Kaiser, the responsibility of sending written notice to Kaiser members, if Kaiser members were affected by the hospital provider's initial notice of termination. In accordance with SCFHP s Confidentiality Policy, and all applicable state and federal laws, any and all information that is required to be kept confidential, shall be kept confidential. 6. Recordkeeping Each department is responsible for retaining and maintaining documents/records/paperwork for a minimum of ten (10) years for their own department (refer to policy LC Record Retention). Page 5 of 5