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.
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