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.