Process for Requesting Termination or Transfer

Provider Type

  • Participating Physician Groups (PPG)

All Levels of Behavior

Formally document each incident of unacceptable behavior on the Transfer/Termination (T/T) Incident Report form (PDF) and send the T/T Request Unit. Include documentation of any counseling sessions with the member regarding unacceptable behavior and any follow-up written notifications. If the counseling session is documented in the member's medical record by the physician, physician assistant (PA) or registered nurse practitioner (RNP), attach a copy of this documentation to the T/T Incident Report. Incidents of unacceptable behavior can often occur in rapid succession, so it is important that the participating physician group (PPG) remain current in its discussions and notification letters. Incidents must be documented as they occur, not retroactively.

When a primary care physician (PCP) or specialist determines that he or she is unable to continue to provide care to a member because the patient-physician relationship has been compromised and mutual trust and respect are lost, a just-cause member transfer may be appropriate. In the United States, the treating physicians and PPGs must always work within the code of ethics established through the American Medical Association (AMA). For information regarding the AMA code of ethics, refer to the AMA website at www.ama-assn.org.

Under the code of ethics, the physician must provide the member with notice prior to discontinuing as the treating physician to enable the member to contact the plan and make alternate care arrangements. However, prior to sending such notice, physicians must also coordinate such transfers with their PPGs' administration department. The plan conducts a fair investigation of the facts before any involuntary transfer for any reason is carried out.

Legally, the plan cannot consider termination unless the PPG or PCP follows the proper procedures outlined below for the applicable level of behavior. The plan must have time for follow-up communication with the member and must allow the member a reasonable time to respond.

  • When sending the T/T Request Unit, the notification letters and T/T Incident Report, include all documentation relating to the incident. The plan and the PPG must have thorough documentation of each occurrence as a former member may take legal action. To ensure that all documentation is current, it is important for the PCP to go through the PPG administration department in contacting the plan.
  • Any T/T Incident Report received in the T/T Request Unit without a copy of the member notification letter is considered incomplete and is returned to the originating PCP or PPG
  • The T/T Request Unit staff assesses the member's warning level and any possible transition of care concerns.
  • A copy of the T/T Incident Report is forwarded to the appropriate provider relations & contracting specialist (formally provider network administrator).
  • The plan must receive the member's statement within 20 calendar days from the time of the plan's receipt of the PPG's notification letter to allow the plan an opportunity to mediate the situation informally

For commercial lines of business, these behaviors can result in a transfer, but not in termination of coverage, except in the case of fraudulent activity.