Non-PCP Provider Termination Clause Samples
The Non-PCP Provider Termination clause outlines the conditions under which a healthcare provider who is not a Primary Care Provider (PCP) may have their participation in a health plan or network ended. This clause typically details the process for termination, such as required notice periods, reasons for termination (like failure to meet quality standards or contractual obligations), and any rights to appeal or review. Its core function is to ensure that the health plan can maintain a network of providers who meet its standards, while also providing a clear and fair process for removing non-PCP providers when necessary.
Non-PCP Provider Termination. If a non-PCP provider, including but not limited to a specialist or hospital, ceases participation in the CONTRACTOR’s MCO, the CONTRACTOR shall provide written notice to members who have been patients of the non-PCP provider. Notice shall be issued no less than thirty (30) days prior to the effective date of the termination of the non-PCP provider when possible or immediately upon the CONTRACTOR becoming aware of the termination.
Non-PCP Provider Termination. If a non-PCP provider, including but not limited to a specialist or hospital, ceases participation in the CONTRACTOR’s MCO, the CONTRACTOR shall provide written notice to members who have been seen and/or treated by the non-PCP provider within the last six (6) months. Notice shall be issued no less than thirty (30) days prior to the effective date of the termination of the non-PCP provider when possible or immediately upon the CONTRACTOR becoming aware of the termination.
21. Section 2.11.8.2.3.1 shall be amended by adding new text and shall read as follows:
2.11.8.2.3.1 The CONTRACTOR shall notify TENNCARE of any provider termination and shall submit an excel spreadsheet that includes the provider’s name, TennCare provider identification number, NPI number, and the number of enrollees affected within five (5) business days of the provider’s termination. If the termination was initiated by the provider, the notice to TENNCARE shall include a copy of the provider’s notification to the CONTRACTOR. The CONTRACTOR shall maintain documentation of all information, including a copy of the actual member notice(s) on-site. Upon request, the CONTRACTOR shall provide TENNCARE a copy of the following: one or more of the actual member notices mailed, an electronic listing in Excel identifying each member to whom a notice was sent,. a transition plan for the enrollees affected, and documentation from the CONTRACTOR's mail room or outside vendor indicating the quantity and date member notices were mailed as proof of compliance with the member notification requirements.
22. Section 2.12.7 shall be amended by adding a new Section 2.12.7.53 and renumbering existing subparts accordingly, including any references thereto.