Notification of Provider Termination Or Change in Location

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Policy/Procedure Number: MP 300 Lead Department: Member Services Policy/Procedure Title: Notification of Provider Termination or External Policy Change in Location Internal Policy Next Review Date: 08/16/2018 Original Date: 02/19/1998 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees Reviewing IQI P & T QUAC Entities: OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC Approving Entities: CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER

Approval Signature: Kevin Spencer Approval Date: 08/16/2017

I. RELATED POLICIES: N/A

II. IMPACTED DEPTS.: N\A

III. DEFINITIONS: A. PCP – Primary Care Provider B. DHCS – Department of Health Care Services C. HMO – Health Maintenance Organization

IV. ATTACHMENTS: N\A

V. PURPOSE: To ensure a smooth transition and timely notification to those members whose Primary Care Provider (PCP), Specialist or Hospital has moved or is no longer available to them through Partnership HealthPlan of California (PHC).

VI. POLICY / PROCEDURE: A. Regulatory Requirements 1. Per the Department of Health Care Services (DHCS) contract, members are notified in writing of any significant changes in the availability or location of covered services or any other significant changes in information listed in 42 CFR 438.10(f)(4), at least thirty (30) calendar days prior to the effective date of such changes. A.1. Whether the changes are significant for the purpose of this sub provision shall be determined solely by DHCS. A.2. In the event of natural disaster or emergency, PHC shall provide notice to the members as soon as possible, but no later than 14 calendar days. A.3. The notification to members must be presented to and approved in writing by DHCS prior to its release.

B. Notification Timelines B.1. PHC Provider Relations staff notifies the Member Services Department of any changes in provider location or provider termination. Notification is done by email. B.2. A member notification letter is mailed by the Member Services Department to all affected members. B.3. Members affected by the change in location or provider termination are notified in writing at least thirty (30) calendar days before the effective date.

of 4 Policy/Procedure Number: MP 300 Lead Department: Member Services Policy/Procedure Title: Notification of Provider Termination or Change in Location ☒External Policy ☐Internal Policy Original Date: 02/19/1998 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: ☒ Medi-Cal ☐ Employees B.4. In the event that adequate notice is not provided to PHC by the provider, the member notification letter is mailed as soon as possible but no later than seven (7) working days from the date PHC received notification. B.5. In the event of a natural disaster or emergency, PHC shall provide notice to members as soon as possible, but no later than fourteen (14) calendar days. B.6. The notification to members must be presented to and approved in writing by DHCS, 60 days prior to its release. B.7. Terminations of Clinics and PCPs that would result in less than 500 members having to change PCPs and all affected members meet the DHCS time and distance standards, may use a DHCS preapproved template without notice to DHCS.

C. Member Notifications C.1. The letter is written at a reading level understandable to PHC members in threshold languages. C.2. Terming medical groups, clinics and PCPs notification letter provides the following information: C.2.a. Reason for termination (applies to Medical Group terms only). C.2.b. Effective date of the termination. C.2.c. Name of the terminating clinic or PCP. C.2.d. Description of how the termination will affect the member’s access to covered services. C.2.e. The member’s new PCP assignment and options for selecting a PCP. C.2.f. A new ID card will be sent or is included with the name and phone number of the assigned PCP. C.2.g. The PHC Member Services Department phone number and hours of operation. C.2.h. The toll free number to DHCS’ office of the Ombudsman. C.2.i. A statement that the member may contact the plan's customer service department to request completion of care for an ongoing course of treatment from a Terminated Provider. C.3. Terminating Hospital notification letter provides the following information: C.3.a. Effective date of termination. C.3.b. Name of terminating hospital. C.3.c. If applicable, name of the member’s current PCP and the name of the PCP to which the member will be reassigned with an option change. C.3.d. Description of how the termination will affect the member’s access to covered services e.g. whether the member has to change their PCP or specialist, how the member will access services. C.3.e. If applicable, the name of another hospital the member is assigned to or can access in the service area. C.3.f. The PHC Member Services Department phone number and hours of operation. C.3.g. The toll free phone number to DHCS’ office of the Ombudsman.

D. Change of Location

of 4 Policy/Procedure Number: MP 300 Lead Department: Member Services Policy/Procedure Title: Notification of Provider Termination or Change in Location ☒External Policy ☐Internal Policy Original Date: 02/19/1998 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: ☒ Medi-Cal ☐ Employees D.1. Primary Care Provider D.1.a. As outlined in this policy, a notification letter is sent to all Medi-Cal members assigned to the PCP. D.2. Specialists D.2.a. PHC sends a notification letter to those members that have been regularly seen by the specialist if the terminating specialist does not notify his/her patients. “Regularly Seen”, is defined as a member seen by the specialist for one (1) or more visits during the last six months by the affected specialist or if the member had a major surgical procedure during the previous year performed by the affected specialist.

E. Termination E.1. Primary Care Provider (physician assigned practice) and Medical Groups E.1.a. The PHC notification letter and a new ID card are sent to all members assigned to the PCP or Medical Group. A current provider directory and selection form are also mailed. E.2. PCP and Specialist Termination within a Medical Group E.2.a. The medical group is responsible to inform all PHC patients “Regularly Seen” by the provider. “Regularly Seen” is defined as: E.2.a.1) Primary Care: Seen by the provider for periodic preventive care on two (2) or more occasions within a two year period. E.2.a.2) Specialist: Seen by the specialist for one (1) or more visits during the last six months by the affected specialist or if the member had a major surgical procedure during the previous year performed by the affected specialist. E.3. Specialist E.3.a. PHC sends a notification letter to those members that have been regularly seen by the specialist if the terminating specialist does not notify his/her patients. “Regularly Seen”, is defined as a member seen by the specialist for one (1) or more visits during the last six months by the affected specialist or if the member had a major surgical procedure during the previous year performed by the affected specialist. E.4. Hospital E.4.a. PHC sends a notification letter to all members assigned or affiliated with the Hospital.

F. Member Notification by the Provider F.1. PHC may assign responsibility of member notification to contracted providers through a written agreement. Providers that assume responsibility for this activity have agreed to notify all members, in accordance with this policy, who are regularly seen by a primary care provider or specialist, who terminates providing care at the practice site. F.2. On an annual basis or as the termination occurs, the provider is required to forward a list of all terminated practitioner(s) with a sample member notification letter for each terminated provider. PHC will use this information to review the site’s performance.

of 4 Policy/Procedure Number: MP 300 Lead Department: Member Services Policy/Procedure Title: Notification of Provider Termination or Change in Location ☒External Policy ☐Internal Policy Original Date: 02/19/1998 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: ☒ Medi-Cal ☐ Employees G. Oversight G.1. Designated Member Services staff maintains the Provider Mailing Termination Log of those providers that have notified members of a change in location or termination. This is done to ensure that members are appropriately notified by the provider. G.2. A copy of all notifications and the list of members assigned to the provider are placed in the "Member Mailing” file. This file is located in the Member Services Department shared drive.

VII. REFERENCES: Title 42 CFR Section 438.10(f)(4) Managed Care Organizations to give members written notice of any “significant” changes to information contained in the plan’s directory.

VIII. DISTRIBUTION: A. Share Point B. Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Director of Member Services

X. REVISION DATES: Medi-Cal 06/21/00; 02/20/02; 04/12/05; 04/13/06; 06/21/06; 08/12/08; 02/18/09; 03/18/10; 03/07/12; 08/07/13; 11/04/13; 4/20/16; 08/16/17

PREVIOUSLY APPLIED TO: Partnership Advantage : MP 300 - 01/01/2007 to 01/01/2015 Healthy Families: MP 300 - 10/01/2010 to 03/01/2013 Healthy Kids MP 300 – 11/01/2005 to 12/31/2016