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Corrective Action Plan

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals

When a participating physician group (PPG) or hospital is not in compliance with plan policies, contractual obligations or regulatory requirements, the Delegation Oversight Department implements a three-step corrective action process to correct the deficiencies:

  • 1st written notice of deficiency and request for corrective action plan (CAP) - this first notice informs the provider that a CAP is required and must be submitted within 21 calendar days of the date of the notice.
    • The delegation oversight compliance auditor or medical program manager (MPM) reviews the CAP for appropriateness and completeness and notifies the provider of whether the CAP is approved.
    • If the plan does not approve the CAP, the provider is notified and given an additional 15 calendar days for revision and resubmission of the CAP to the plan.
  • 2nd notice of deficiency and request for CAP - this second deficiency letter is sent to a PPG that did not respond to the first notice of deficiency or that cannot demonstrate compliance. The provider is given an additional five calendar days from the date of the letter to submit the previously requested CAP.
    • Providers that do not respond to the second notice are presented to the Delegation Oversight Committee (DOC) for recommendations or sanctions.
  • Final notice (breach notice) - this third deficiency letter and breach of contract notification is sent upon receipt of the decision from the DOC and notifies the PPG of the plan's intent to begin the formal termination process of the PPG's Provider Participation Agreement (PPA).
    • The PPG is informed that the sanction may be avoided if the PPG submits an acceptable CAP to the plan within 15 calendar days of receipt of the final notice and completes or demonstrates substantial progress toward completing the corrections within 30 calendar days.
Last Updated: 11/19/2019