PCP’s Request to Disenroll a Member from their Panel
A Plan physician or provider may not seek or request to terminate a member on his/her panel or transfer a member to another health care provider based on the member’s medical condition, the amount or type of care required by the member or the cost of covered services required by the member.
If a member is approved for transfer, the membership acceptance must be without regard to color, gender, race, religious belief, national origin or handicap of the member.
It is the responsibility of the provider to document in the member’s medical record his/her efforts to develop and maintain a successful professional/member relationship, as well as the failure of members to show for their appointments and the failure to follow the plan of care prescribed. In addition, providers may request assistance from Member Services in contacting the member or referring him/her to Care Management in cases of non-compliance.
If it is determined that a successful professional/member relationship cannot be established or maintained, the physician or provider will notify SHP in writing of the problem, with detailed supporting written documentation. The PCP will continue to provide medical care to the SHP member, until the time that the Plan has reviewed and transferred the member from the physician’s or provider’s panel to a new physician or provider and notified the PCP that a transfer has been completed. SHP and AHCA will be monitoring such activities.
For a PCP to request to disenroll a member from their panel for non-compliance, the following needs to occur and there needs to be documentation on the medical record:
1. Reasons for failure to establish and maintain a relationship with the patient
2. The PCP has made every effort to help the member in correcting the situation, i.e., failure to show to appointments (at least 3 consecutive appointments within 6 months) or failure to follow the plan of care
3. The PCP has notified the member and SHP via certified mail of his/her intention to terminate the doctor-patient relationship. The letter must state the intended effective date (at least 30 days after the date on the letter) and information that the PCP will continue to provide care until the date of change, as well as instructions to obtain additional assistance and change of PCP by calling the SHP Member Services number on the back of their SHP ID card.
