PHYSICIAN TERMINATION BY PLAN:
Before terminating a contract with physician or provider, a written explanation of the reason(s) must be provided. Notice is given to the physician/provider at least 60 days before the termination date, without
cause as stipulated in the physician agreement. Nonetheless, CarePlus may immediately suspend or terminate a provider under circumstances including, but not limited to the following:
* Termination, suspension, limitation, voluntary surrender or restriction of professional license or other government certification/licensure;
* Conviction of a felony or any other criminal charge;
* Any disciplinary action taken by the Drug Enforcement Agency (DEA); or
* Any other legal, government or other action or event which may materially impair the ability to perform any duties or obligations under the provider’s agreement with CarePlus.
Physicians terminated by CarePlus are entitled to an advisory panel hearing. However, the right to request a review is not applicable when a provider fails to maintain professional licensure or any governmental authorization required to provide services under the terms and provisions set forth in the provider agreement.
Please note the following:
* Denials of initial participation in CarePlus are not subject to an advisory hearing review.
* The hearing review applies only to terminations initiated by CarePlus.
* The physician must submit his/her request in writing to CarePlus if they opt for an advisory hearing review.
* The request, along with supporting written documents must be dated and post marked not more than fifteen (15) calendar days following the date of the termination notice. If the request is not received within the fifteen (15) calendar day time frame, the physician’s right to review is waived.
* An Advisory Panel Review will consist of three (3) physicians who are peers of the physician.
However, at least two (2) members of the Advisory Panel must be present at the review to constitute a quorum.
* The Advisory Panel will base its recommendation on the written information presented by the physician and CarePlus, along with any additional information requested by the Panel.
* The review will occur prior to the effective date of the termination decision, and in most cases, within 15 business days of CarePlus’ receipt of the physician’s request for the review.
* A Provider Operations representative shall send a notification letter via certified or registered mail to the Provider(s) within two (2) weeks of receipt of the Advisory Panel’s decision.
Members will be given reasonable advance notice of the impending termination of any provider. Members currently under treatment with a Specialty Care Physician may be able to continue to receive care for a limited time. Continuity of care determinations will be made on a case-by-case basis by the Plan. However, please note that continuity of care will not offered to members if a provider is terminated for violations of medical competence or professional behavior, decredentialed, relocated outside of the Plan’s service area or retires.
IMPORTANT: In the event of a provider termination, the terminated provider is responsible for transferring the members’ medical records.
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
CPT CODE and Description 90785 - Interactive complexity (List separately in addition to the code for primary procedure) 90791 - Psychi...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Procedure code and description 95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory air...
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...