Closure and Termination

Participating physician groups (PPGs) are required to notify the regional Provider Network Management Department in writing at least 90 days in advance of the date that a subcontracting provider does the following:

• Closes the medical practice.
• Terminates the relationship with the PPG.

For Medicare plans, the plan notifies affected members 30 days in advance, whenever possible, of a primary care physician (PCP) termination. The notification is sent by U.S. mail, and includes instructions on selecting a new PCP.

For Medicare HMO plans, capitated and shared-risk PPGs must notify members in writing at least 30 days in advance of a specialist or ancillary provider termination effective date, and the template sent to members must be approved by the Centers for Medicare & Medicaid Services (CMS).¹ The plan's CMS-approved Medicare termination notification template (PDF) must be completed by the PPG and mailed to the member.

The plan may allow a member to continue using a terminated provider when:

• A member had been receiving care for an acute or chronic condition, in which case care by the terminated provider is covered for 90 days or longer, if necessary, for a safe transfer of the member.
• A member is pregnant, in which case care by the terminated provider is covered until postpartum services related to the delivery are completed or longer, if necessary, for a safe transfer of the member.

The terminated provider is subject to the same contractual terms and conditions imposed prior to termination until medical care to the member is completed. These terms and conditions include, but are not limited to:

• Credentialing
• Hospital privileging
• Utilization review
• Peer review
• Compensation

Refer to the Transition of Care topic for more information.

Refer to definition of Opt Out Provider for more information.

¹Title 42 of the Code of Federal Regulations (CFR) section 422.111(e))