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.
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