The following situations are considered just-cause reasons for members to request a participating physician group (PPG) transfer at any time:

The PPG may request that a member be transferred only when there is just-cause for the transfer. Just-causes are those circumstances that result in a breakdown in the relationship between the member and provider, such as legal action or member behavior.

The PPG is asked to supply documentation and an opinion on the merits of the case. The plan expects the PPG to take reasonable action to satisfy the member by arranging a transfer to a different physician or attempting to remedy the problem before the plan arranges a transfer.

Case documentation must include the PPG's written notification to the member, as required according to the procedures for level A behavior, level B behavior and level C behavior. The written member notification must include:

The plan reviews all information and decides whether to honor the request based on the compiled results of all research. In cases involving legal action or member dissatisfaction, the PPG initiates the transfer request by sending the Transfer and Termination Incident Report - Commercial (PDF) or Transfer and Termination Incident Report - CalMediConnect/Medicare (PDF)) to the Transfer/Termination (T/T) Request Unit, outlining the problem and attaching all supporting documentation. The plan researches the situation and informs the affected PPG of its decision. The effective date of the transfer is determined on a case-by-case basis depending on the circumstances; however, a current date is always the optimum choice.

When the plan approves a transfer for just cause, the PPG to which the subscriber is being transferred is informed of the transfer and when it will occur. In these instances, as with open enrollment and address changes, the receiving PPG must accept the member. Refer to the Provider Participation Agreement (PPA) provisions addressing the PPG's acceptance of all HMO members provided that the PPG and its participating physicians have the capacity to provide contracting services, and PPG and participating physicians continue to accept new members from any other health care service plan.

The plan, at its own discretion, determines whether a member is transferred for just-cause without receiving PPG approval. Such transfers are arranged as necessary.

Each month, the plan mails each PPG copies of letters sent to members indicating a PPG transfer. The PPG is expected to review these letters and use them to update the current eligibility list. The PPG is also expected to provide or deny services.

When a PCP or specialist determines that they are 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.