Provider Relations Procedure Number: EN.001v1.02
Title: Member Involuntary Disenrollment
Dates: Procedure Effective: 07/31/1996
Date of Origin: 07/31/1996
Last Review Date: 12/08/2008
Last Revised Date: 12/08/2008
Product Line(s): þ Healthy Options þ Basic Health þ Medicare Advantage þ GAU N/A
Ownership: Author: K. Gilreath, Provider Relations Staff and Network Education Coordinator
Approver:
B. Fountain, Regional Provider Relations Manager
Purpose:
To outline the process by which a member may be involuntarily assigned to a different provider or disenrolled from Community Health Plan
Dependencies
The Member Involuntary Disenrollment policy drives the outcome of this procedure.
The PCP Reassignment procedure feeds or uses results of this procedure.
Procedure
1. Providers at Community Health Plan clinic sites will, in accordance with their internal policies and procedures, document and address instances of member non-compliance or misbehavior.
2. Clinics may request that the Plan reassign or disenroll a member if the member’s behavior repeatedly falls under one or all of the following descriptions:
2.1 Member exhibits repeated abusive behaviors toward staff or visitors: this behavior may include yelling, the use of profanity or name-calling; any inappropriate or unwelcome touching, or threatening words or actions;
2.2 Member refuses to follow outlined diagnostic treatment plan or continually engages in drug-seeking behavior;
2.3 Member repeatedly refuses to follow the procedures of the clinic or member handbook by continually missing appointments, by inappropriately using the emergency room, or by self-referring to specialists without consulting with the primary care physician.
3. To initiate a reassignment or disenrollment, the following steps must be followed:
3.1 The appropriate clinic staff member will send a warning letter to the member. This letter will clearly document instances of misbehavior and outline steps of a written plan that the member must follow if he/she wishes to continue to receive health care at the site. Warning letters will be copied to the Clinic Managed Care Coordinator and the Community Health Plan Provider Relations Coordinator. The member will be provided written copies of the clinic’s written procedures relating to patient behavior.
3.2 If the member repeats the behavior in question or chooses not to follow the steps outlined, clinic staff, with the approval of the Clinic Medical Director, will consult with the Provider Relations Coordinator at Community Health Plan to request that the member be reassigned or, in the most serious cases, disenrolled from the Plan. Plan and/or clinic staff will determine the feasibility of reassigning the member within the Community Health Plan network. The Plan Program Manager will interview the member if possible and appropriate.
3.2.1 If reassignment is not an option due to member’s location or circumstance, a plan for resolution and follow-up that includes member education will be established by the staff involved.
3.2.3 If after reviewing the case, there is agreement that the member should be reassigned to another clinic, the clinic will inform the member in writing of the decision. This letter will provide thirty (30) days notice. Copy of letter is sent to their Provider Relations Coordinator.
3.2.4 The Provider Relations Coordinator will record receipt of member dismissal letter on the Notes tab in the Member Inquiry screen. Copy of letter is forwarded to Customer Service for member follow up.
3.2.5A representative from Community Health Plan’s Customer Service will make three (3) attempts to contact member to give him/her alternative PCP options. If no response after three (3) attempts, Community Health Plan will chose another PCP for member. New ID card will be sent to the member.
3.2.6 If, after reviewing the case, the clinic and the Plan Program Manager determine that the member’s behavior is serious enough to warrant disenrollment from the Plan, the Program Manager will forward the case to the state or federal agency for a determination. The Plan Program Manager will inform the member in writing of the decision. This letter will provide thirty (30) days notice and will inform the member of his or her right to appeal the decision and the right to a fair hearing under Washington Administrative Code.
4. While the request to disenroll the member is pending, the Plan Program Manager will work with clinic staff and the member to arrange for the member’s health care. In the event that the State denies the request for disenrollment, Community Health Plan will maintain responsibility for the member’s health care per our contract under the member’s plan.
Clinic staff are responsible for documenting client misbehavior; creating a written action plan for improvement if applicable; providing members with written notice about action the clinic plans to take; providing members with written procedures relating to a member’s responsibility, and reporting to law enforcement agencies any criminal behavior.
The Community Health Plan Program Manager is responsible for reviewing documentation and consulting with clinic staff to determine alternatives for providing care for the member. If this is not possible, the Community Health Plan Program Manager serves as a liaison to the State when requesting disenrollment.
Regulatory References:
CFR Citation: / 482.226; 438.56(b), (1), (2), (3)State Regulations: / WAC 388-538-130
Revision History:
Revision Date / Revision Description / Revision Made By12/08/2008 / Added PRC and CS responsibilities / K. Gilreath
11/24/08 / Updated to new template / K. Gilreath
Member Involuntary Disenrollment
Revised: 12/04/2008 EN.001v1.02 EN.001v1.02
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