Anthem Blue Cross Provider Operations and Technology

Transcription

1 Termination of Provider Enrollee Notification Initial Policy Approval Date: 12/17/2001 Policy Review/Revision Approval Date(s): 06/17/2002, 6/16/2003, 3/29/2004, 06/19/2007 Filed DMHC, 1/17/2014 Products: HMO/POS, PPO/EPO Commercial (DMHC-Regulated) HOSPITAL AND HMO PROVIDER GROUP NETWORK TERMINATIONS It is the policy of Anthem Blue Cross ( Anthem ) to comply with applicable state law and regulations regarding provider terminations. This policy specifically addresses the provider termination planning, regulatory filing, and member notification process for Anthem s Commercial line of business. When the contract between an acute care hospital or HMO participating medical group ( provider group ) and Anthem terminates, Anthem is required to file a Transition Plan, also known as a Block Transfer, to the California Department of Managed Health Care ( DMHC ) in accordance with state law and regulations. Each Transition Plan must include a copy of the Enrollee Notice that Anthem proposes to send to potentially affected subscribers and/or members. The company will proceed to implement its Transition Plan for a Hospital or HMO Provider Group contract termination and mail Enrollee Notices under the following circumstances: The DMHC reviewed and approved the company s Transition Plan and proposed Enrollee Notice. The DMHC did not respond to the company within seven calendar days after the submission of a Transition Plan and Enrollee Notice. In this case, the Transition Plan and Enrollee Notice are deemed to be approved. The DMHC is not required to render a decision on the Transition Plan (for example an Information- Only filing), then the company proceeds as if the Transition Plan were deemed approved. The company files a waiver application with the DMHC, in cases when it has received an untimely notification of a hospital s or provider group s contract termination, and the DMHC does not respond within seven days of receipt, then the company complies with the timeframes indicated in the waiver request. When the submission of a Transition Plan is unnecessary, such as when the terminating provider group s Plan enrollment is less than 2,000. PROCESS MANAGEMENT The Regulatory Affairs Department ( RAD ) of the Provider Engagement & Contracting unit manages the network disruption planning process and hosts weekly Transition Planning Team ( TPT ) meetings to discuss potential provider contract terminations and related operations planning to: 1. Ensure that the Transition Plan filing process is complaint with state law, DMHC regulations, Health and Safety , and all other regulatory requirements. 1 Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ANTHEM is a registered trademark. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

2 Termination of Provider: Enrollee Notification 2. Develop and file the Transition Plan and proposed Enrollee Notification with the DMHC. 3. Notify Plan members; providers; and agents, brokers, and clients about the situation, as described herein. 4. Provides instruction relative to the redirection of Plan membership to alternate facilities and/or HMO enrollment to new receiving provider groups; including ensuring new member identification (ID) cards are issued when necessary. 5. Share information with all Anthem departments responsible for addressing enrollee and provider concerns. 6. Inform regulators when situations may result in a provider termination and provide status updates. The TPT meeting includes, but is not limited to, associate representation from: RAD, Provider Contracting, Network Relations, Network Communications, Client Services, Individual, Small Group, Large Group, Medicare, Transition Assistance/Continuity of Care, Legal, HMO Finance, Enrollment and Billing, Corporate Communications, Government Affairs, Provider Database Operations, Case Management, Sales Communications, Claims Operations, Customer Care, and other company departments as necessary. PROCEDURE The following information details the procedures specific to provider group contract terminations, hospital contract terminations, PCP/specialist terminations, and PPO physician terminations. A. Transition Plan Development 1. Provider Group Terminations Anthem submits enrollee transfer filings to the Department of Managed Health Care (DMHC) 75 days prior to a medical group/ipa termination. Transition Plans are completed for HMO provider groups if the contract is scheduled to terminate and the potentially affected Plan enrollment is 2,000 or more. However, the 2,000 member threshold does not relieve Anthem of other regulatory obligations, such as notifying potentially affected subscribers about the situation 60 days in advance. Anthem begins its transition planning process approximately six months in advance of a contract s termination and/or promptly upon written notification if less time is given. When written notice from a HMO provider group is received with intent to terminate a contractual agreement with the company, the planning process is facilitated by RAD. The potential provider group termination is discussed during the weekly TPT meetings and all milestones are tracked, including pre-transition Plan filing responsibilities, undertakings during the DMHC s review, and post-transition Plan requirements. Contract extensions will alter the timelines. a) Identifying the alternate HMO provider groups (aka receiving provider groups) to redirect enrollees 2

3 Termination of Provider: Enrollee Notification The company conducts an enrollment analysis (referred to as an internal crosswalk ), which lists the number of members assigned to the terminating provider group, broken down by product line: Individual, Small Group, Large Group, National, etc. The internal crosswalk identifies the closest PCP(s) to each member s home address. If the provider group termination is an Independent Physician Association ( IPA ) business model, whereby Anthem members are enrolled under the care of a specific PCP, the analysis will also include a list of PCP identifiers and the names of the members assigned to those PCPs within the IPA. Note: this additional data element cannot be provided for contract terminations with Participating Medical Group ( PMG ) business models because they are staff models, i.e., members assigned to a PMG are not enrolled under the care of a specific PCP, rather they are assigned to the site/location. Reasonable efforts are made to allow members to continue receiving care from their current PCP when he or she practices with multiple provider groups. To help accommodate this, the internal crosswalk indicates the business names of the alternate provider groups with which the terminating IPA s PCPs are affiliated. From the Crosswalk, the TPT identifies the potential receiving provider groups to which Anthem members can be transferred if/when the contractual agreement between the provider group and the company terminates. The potential receiving provider groups are further reviewed with the Contract Manager assigned to the contract negotiation and any appropriate changes are made. When determining the receiving provider groups, the company considers the following: Proximity to the affected members home addresses according to the DMHC guidelines. If the receiving provider group(s) is/are contracted with any of the terminating PCPs the company makes every effort to maintain the Member/PCP relationship through alternate PCP affiliations with other contracted provider groups. If the receiving provider group(s) is/are contracted with the company for all product lines affected by the termination (e.g., members in a narrow network product can only be reassigned to a provider group that participates in the same narrow network). If the receiving provider group(s) is/are currently involved in contract negotiations with the company and the status of the negotiation. If the receiving provider group(s) is/are willing, and has the financial and administrative capacity, to accept the additional enrollment. If the receiving provider group(s) is/are under a Corrective Action Plan. Once the receiving provider groups are identified, the internal crosswalk is finalized to include the number of Plan members who will be reassigned to each receiving provider group; a breakdown of the membership by affected product; the number of members who will be able to maintain their current PCP-relationship with their new receiving provider group; and the PCPto-PCP transfer information (for IPAs) to be used by the appropriate department to properly reassign the members. The number of members who cannot be matched with their current PCP at the same location are reported to the DMHC using a Provider Reassignment Chart. When a member cannot be 3

4 Termination of Provider: Enrollee Notification matched to his or her PCP through an alternate receiving provider group, they are often referred to as no-matches and this information is shared in the Transition Plan. b) Enrollee Notice (HMO/POS Member Notification Letter) A proposed Enrollee Notice (Attachment A) is prepared, which is subsequently mailed to all members assigned to a terminating provider group. The template letter is filed with the Transition Plan for the DMHC s review and approval when a Transition Plan is required to be filed with the State, e.g., when there are more than 2,000 Plan members enrolled with the provider group. The letter advises members of, among other things, the effective date of the termination, how to self-select a different PCP or provider group that differs from the new assignment, and contact information to address any concerns such as continuation of care. After the transition filing is approved by the DMHC, the enrollee notice is mailed to enrollees assigned to the HMO provider group at least 60 days in advance of the contract termination. The same regulatory timelines relative to notifying affected enrollees applies to HMO provider groups with less than 2,000 enrollees. It is Anthem s practice to cease contract negotiations with a terminating provider group once Enrollee Notices are distributed. However, in the rare event agreement is reached with a terminating/terminated provider group after the Enrollee Notices have been sent, but within 30 days after the effective date of the termination, the company will distribute a follow up notice to members (Attachment D) informing them that a new contract is effective. The notice advises members that they can switch back to their former PCP and/or provider group online or by calling the Customer Service telephone number listed on their medical ID card. 2. Hospital Terminations Anthem files a Transition Planwith the DMHC for all acute care hospitals no later than 30 days prior to the effective date of a hospital s contract termination. The company begins the transition planning process approximately six months in advance of a termination and/or promptly upon written notification if less advance notice is provided. Once a notice of contract termination is sent to or received from a hospital stating the intent to terminate the contract (often stated as renegotiate/terminate), a copy of the letter is provided to the Transition Planning Team or TPT. The transition planning process for the hospital or hospital system is facilitated by the TPT. The potential hospital termination is discussed during the weekly meetings and all milestones are tracked, including pre-transition Plan filing responsibilities, undertakings during the DMHC s review, and post-transition Plan requirements. Contract extensions will alter the timelines. Members are not assigned to hospitals, and therefore are not block transferred to another facility when the contract terminates. Rather, members may obtain services from any participating hospital to which their physician or medical group maintains admitting privileges or otherwise arranges for admission (for example, use of a Hospitalist Program). PPO Physicians and HMO provider groups are contractually obligated to admit members to a participating network hospital (PPO physicians and HMO provider groups are not limited or obligated to admit members to a particular designated facility). 4

5 Termination of Provider: Enrollee Notification Anthem queries a list of alternate participating acute care hospitals in the terminating facility s service area, and includes those nearby with similar services to that of the terminating hospital. Selection of the alternate hospitals follows the DMHC s geographic access guidelines of 15 driving miles or 30 driving minutes from the terminating hospital. The list of alternate participating hospitals is generated, which also takes into account the accommodation of the additional patient volume that could result from the redirection of patients away from the terminating hospital. There are several factors that are considered when identifying the alternate hospitals in the service area: Which alternate hospitals do not have a pending or potential contract termination, and gauge the status for those that are in negotiations. Which are closest to the terminating facility (15-mile/30-minute driving radius). Which facilities have comparable services to those offered by the terminating hospital. Which hospitals have a reasonable number of physicians with admitting privileges at both the terminating hospital and alternate hospitals. Which alternate hospitals have occupancy rates under 80 percent and/or reach out to those with occupancy rates above 80 percent to determine their ability and willingness to accept additional volume, and whether there are considerations that must be taken into account because of potentially increased admissions. Anthem contact(s) the alternate hospitals based on occupancy rates and service inventories that are required to meet the needs of our members who could be potentially redirected to one of the alternate facilities. Anthem verifies the alternate hospitals have sufficient available bed capacity to accept additional Plan member admissions should the contract with the hospital actually terminate. Occasionally, when an alternate hospital fails or refuses to respond to a capacity request, it is necessary to refer to the hospital's website and The Office of Statewide Health Planning and Development s ( OSHPD ) online information, which the State receives directly from each hospital in California. Next, a list of provider groups with admitting privileges to the terminating hospital is researched as well as the number of PPO physicians by specialty. Anthem verifies that the admitting provider groups can admit members (directly or through a Hospitalist) to one or more of the alternate facilities that are geographically accessible to the service area and have a similar range of services to that of the terminating hospital. The proposed Enrollee Notice template letter for a hospital termination (Attachment B), among other things, advises members of the effective date of the potential termination, explains how members can check the participating status of network facilities, provides a list of nearby alternate participating hospitals, explains what to do if a member receives a bill from the terminated hospital; and contact information to address questions such as continuity-of-care/continuation-of-covered-services. After the Transition Plan is approved by the DMHC, the enrollee letters will be mailed within five calendar days after the effective date of the hospital s contract termination. The letter is sent to enrollees who have outstanding authorizations for services or procedures scheduled to occur at the terminating hospital within 180 days subsequent to the termination date as well as enrollees who utilized the terminating hospital within the past 12 months. B. Member Transition 5

6 Termination of Provider: Enrollee Notification HMO Provider Group: No later than 5 days before the effective date of an HMO provider group contract termination, members receive a new identification card, which includes the name and address of the member s new provider group. Members may continue to receive services from the terminating provider until the effective date of the contract termination. Using the internal crosswalk, the appropriate department, e.g., Enrollment & Billing, Provider Database Operations, Customer Service, etc., make the appropriate system changes to the membership. The Network Relations Department, which participates in the TPT, often oversees systematic member transitions to new provider groups by working directly with associates from the departments mentioned above. Hospital: In the event contractual agreement cannot be reached with a terminating hospital, the Provider Database Operations Department marks the terminated hospital as non-participating on the provider database and all directories are subsequently updated as a result. C. Notice of PCP and Specialist Terminations from an HMO Provider Group If a PCP (or group practice of PCPs) terminates his or her participation with an HMO provider group that participates with Anthem, then Anthem Blue Cross sends a written notice concerning the PCP(s) termination to assigned members (Attachment C). Members are generally reassigned to another PCP within the same HMO provider group at the same practice location. If a specialist (or group practice of specialty care providers) terminates his or her participation with an HMO provider group that participates with Anthem, then the participating provider group is delegated to notify the appropriate HMO members about the provider termination and assisting the members in obtaining services from another participating network specialist. Anthem Blue Cross audits this member notification process during routine site audits. D. Notice of PPO Physician Terminations Although notice is not statutorily required when a PPO physician terminates his or her agreement with Anthem, certain accrediting organizations require a member notification process. Accordingly, in the event a PPO physician terminates from a provider network, Anthem will send a notice regarding the termination to those PPO members who sought treatment from the physician during the previous 12 months (Attachment E). ATTACHMENTS: A. Sample Enrollee Notification Letter HMO Provider Group Termination B. Sample Enrollee Notification Letter Hospital Termination C. Sample Enrollee Notification Letter Primary Care Physician Termination D. Sample Enrollee Notification Letter Agreement Reached with HMO Provider Group E. Sample Enrollee Notification Letter PPO Physician Termination 6

7 Termination of Provider: Enrollee Notification REFERENCE SOURCES NCQA QI 9 Health & Safety Code Section , CCR Anthem Blue Cross Clinical Strategies and Operations Policy CSO 6 Continuity of Care, Transition Assistance Sample Delegation Agreement Specialist Terminations Provider Terminations-Member Notification (Anthem Medicaid Policy) 7

8 Termination of Provider: Enrollee Notification Attachment A Sample Enrollee Notification Letter - HMO Provider Group Termination Date«FNAME» «LNAME» «ADDRESS1» «CITY», «ST» «ZIP» Dear Anthem Blue Cross Member: Our records indicate that you are currently assigned to [Medical Group Name]. This letter is to inform you that [Medical Group Name] s contract agreement with Anthem Blue Cross will terminate effective [date]. As a result, it will no longer be part of the Anthem Blue Cross HMO Network beginning [date]. There is nothing you need to do. We understand the importance of maintaining the patient/doctor relationship. Every effort will be made to keep you assigned with your current primary care physician if he or she practices with another Anthem Blue Cross participating medical group. A new Anthem Blue Cross identification (ID) card will be mailed to you no later than five days before the [date] effective date. We encourage you to contact your new medical group once you receive your new ID card and familiarize yourself with the medical group. For example, the specialists and hospitals used by the new medical group may be different from those offered by [Medical Group Name]. You will also be able to use the Find a Doctor Internet feature available on anthem.com/ca to see the physicians available to you. What if I want to select a different doctor or medical group? Once you receive your new ID card, if you wish to choose another Anthem Blue Cross primary care physician within your area, you can use the Find a Doctor feature available at anthem.com/ca, or contact us using the toll-free number on your current ID card. What if I am currently receiving care from [Medical Group Name]? We realize that if you are in a course of treatment it s important to not interrupt that care. Please contact us using the toll-free number on your current ID card if you: Are pregnant Currently receiving ongoing medical care Have a newborn child up to 36 months old who is receiving care Have a current authorization for health care services Otherwise concerned that this change will disrupt your care You can request completion of care or ask for further explanation of your rights to continued care. An Anthem Blue Cross Customer Service representative can assist you. Eligibility for continuity of care depends on factors outlined in your Evidence of Coverage and Anthem Blue Cross Continuity of Care Policy. You can access and print Continuity of Care Policies online by visiting our website, At the bottom of the webpage, click on the Providers link under Other Anthem Websites. A new webpage will open. Click the Enter button. On the Provider Home page, click the Communications tab along the top of the webpage. On the Communications 8

9 Termination of Provider: Enrollee Notification page, click the Anthem Blue Cross Continuity and Coordination of Care Policies link. From the Anthem Blue Cross Continuity and Coordination of Care Policies page, select the policy you would like to view. Who do I contact if I have more questions or concerns? Anthem Blue Cross is required by law to provide you with the following information: If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Please contact Anthem Blue Cross customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO consumers, by telephone at its toll-free number, HMO-2219, or at a TDD number for the hearing impaired at , or online at: Are my health care benefits changing? No, your enrollment in your Anthem Blue Cross plan remains the same and is not otherwise affected in any way. As always, if you receive a bill for covered services other than co-payments, co-insurance, or deductibles, please call Anthem Blue Cross Customer Service at the telephone number on your ID card so that it can be reviewed by our staff. If you are enrolled in a point-of-service (POS) plan and continue to access [Medical Group Name] after the termination date, you may have significantly higher out-of-pocket costs. Your Evidence of Coverage outlines your coverage for seeking care from a provider who is not part of our network. Also, Customer Service can provide this information. Your health care needs are very important to us, and we are committed to providing you with exceptional service. Please be assured that your health care coverage will not be interrupted and that this change will not result in a change to your covered benefits. Si usted necesita asistencia en español, por favor llame al Departamento de Servicio al Cliente de Anthem Blue Cross al número de teléfono gratis en su tarjeta de identificación. Sincerely, Anthem Blue Cross 9

10 Termination of Provider: Enrollee Notification Attachment B Sample Enrollee Notification Letter Hospital Termination «date FNAME» «LNAME» «ADDRESS1» «CITY», «ST» «ZIP» Dear Anthem Blue Cross Member: This letter is to inform you that [Name of Terminating Hospital] is no longer a participating provider in Anthem Blue Cross network, effective [date]. Anthem Blue Cross physicians who admit to [Name of Terminating Hospital] have been notified of this development and will arrange for admission of Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company members to alternate facilities. To check the participating status of Anthem Blue Cross facilities, please consult Anthem Blue Cross website at anthem.com/ca. A partial list of alternate, contracted facilities includes: [Insert Name of Alternate Hospital] [insert Name Alternate Hospital] [Insert Name of Alternate Hospital] [Insert Name of Alternate Hospital] If you are pregnant, currently undergoing a course of treatment, or if you have a current authorization for health care services, you may be eligible for transition assistance to ensure continuity of care. Please call our toll-free telephone number on your identification card. An Anthem Blue Cross Customer Service representative will be happy to assist you. If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Please contact the Anthem Blue Cross customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO/PPO consumers, by telephone at its toll-free number, HMO-2219, or at a TDD number for the hearing impaired at , or online at If you are enrolled in a point of service (POS) plan or preferred provider organization (PPO) and continue to access [Name of Terminating Hospital] after the expiration date, you may have significantly higher out of pocket costs. Your Evidence of Coverage outlines your coverage for seeking care from a provider who is not part of our network. Also, Customer Service can provide this information. Emergency medical services do not require pre-authorization regardless of where services are delivered. Members may go to any hospital for emergency services, including [Name of Terminating Hospital]. This coverage will be provided according to your policy benefits. 10

11 Termination of Provider: Enrollee Notification Your enrollment in your Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company plan remains the same and is not otherwise affected in any way. If you receive a bill from [Name of Terminating Hospital] that exceeds the amount indicated as the member responsibility on the Explanation of Benefits you receive from Anthem Blue Cross/Anthem Blue Cross Life and Health Insurance Company for services rendered after [insert date one day prior to termination effective date], please contact Anthem Blue Cross at the toll free number on your ID card, so that it may be handled appropriately. Your health care needs are very important to us, and we are committed to providing you with exceptional service. Please be assured that your health care coverage will not be interrupted and that this hospital s termination will not result in a change to your covered benefits. Si usted necesita asistencia en español, por favor llame al Departamento de Servicio al Cliente de Anthem Blue Cross al número de telefono gratis en su tarjeta de identificacion Sincerely, Anthem Blue Cross 11

12 Termination of Provider: Enrollee Notification Attachment C Sample Enrollee Letter Primary Care Physician Termination DATE «NAME» «ADDRESS1» «ADDRESS2» «CITY», «ST» «ZIP» «ID» Dear Anthem Blue Cross Member, Your currently assigned [Medical Group Name] has notified Anthem Blue Cross that its relationship with your primary care physician will terminate, effective [date]. As a result, your primary physician will no longer be part of the Anthem Blue Cross Network beginning [date]. There is nothing you need to do. We understand the importance of maintaining the patient/doctor relationship. In order to ensure the continued availability of health care services for Anthem Blue Cross members, effective [date], you will be reassigned to an alternate primary care physician and/or medical group. A new Anthem Blue Cross identification (ID) card will be mailed to you no later than five days before the [date] effective date. What if I want to select a different doctor or medical group? Once you receive your new ID card, if you wish to choose another Anthem Blue Cross primary care physician within your area, you can use the Find a Doctor feature available at anthem.com/ca, or contact us using the toll-free number on your current ID card. What if I am currently receiving care? We realize that if you are in a course of treatment it s important to not interrupt that care. Please contact us using the toll-free number on your current ID card if you: Are pregnant Currently receiving ongoing medical care Have a newborn child up to 36 months old who is receiving care Have a current authorization for health care services Otherwise concerned that this change will disrupt your care You can request completion of care or ask for further explanation of your rights to continued care. An Anthem Blue Cross Customer Service representative can assist you. Eligibility for continuity of care depends on factors outlined in your Evidence of Coverage and Anthem Blue Cross Continuity of Care Policy. You can access and print Continuity of Care Policies online by visiting our website, At the bottom of the webpage, click on the Providers link under Other Anthem Websites. A new webpage will open. Click the Enter button. On the Provider Home page, click the Communications tab along the top of the webpage. On the Communications page, click the Anthem Blue Cross Continuity and Coordination of Care Policies link. From the Anthem Blue Cross Continuity and Coordination of Care Policies page, select the policy you would like to view. Who do I contact if I have more questions or concerns? Anthem Blue Cross is required by law to provide you with the following information: 12

13 Termination of Provider: Enrollee Notification If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Please contact Anthem Blue Cross customer service department, and if you have further questions, you are encouraged to contact the Department of Managed Health Care, which protects HMO consumers, by telephone at its toll-free number, HMO-2219, or at a TDD number for the hearing impaired at , or online at: Are my health care benefits changing? No, your enrollment in your Anthem Blue Cross plan remains the same and is not otherwise affected in any way. As always, if you receive a bill for covered services other than co-payments, co-insurance, or deductibles, please call Anthem Blue Cross Customer Service at the telephone number on your ID card so that it can be reviewed by our staff. If you are enrolled in a point-of-service (POS) plan and continue to access your primary care physicians after the termination date, you may have significantly higher out-of-pocket costs. Your Evidence of Coverage outlines your coverage for seeking care from a provider who is not part of our network. Also, Customer Service can provide this information. Your health care needs are very important to us, and we are committed to providing you with exceptional service. Please be assured that your health care coverage will not be interrupted and that this change will not result in a change to your covered benefits. Si usted necesita asistencia en español, por favor llame al Departamento de Servicio al Cliente de Anthem Blue Cross al número de telefono gratis en su tarjeta de identificacion Sincerely, Anthem Blue Cross 13

14 Termination of Provider: Enrollee Notification Attachment D Sample Enrollee Letter Agreement Reached with HMO Provider Group <Date> «FNAME» «LNAME» «ADDRESS1» «ADDRESS2» «CITY», «ST» «ZIP» «ID» Dear Anthem Blue Cross Member, In a letter dated, <DATE OF ORIGINAL LETTER>, we notified you that <NAME OF TERMINATED GROUP> would no long participate in Anthem Blue Cross HMO Network, effective <DATE OF TERMINATION>. You were advised that you would be assigned to an alternate participating medical group on <DATE OF TERMINATION>. Since we notified you of this change, Anthem Blue Cross and <NAME OF TERMINATED GROUP> were successful in reaching an agreement. You now have the option to: 1) Re-enroll with <NAME OF TERMINATED GROUP> and remain with your current primary care physician after <DATE OF TERMINATION>. If this is what you would like, please contact us using the Customer Care telephone number located on your membership card to inform us of you choice. 2) Select a medical group and primary care physician of your choice from our list of contracting provider groups, which is available on Find a Doctor, If this is what you would like, please contact us using the Customer Care telephone number located on your membership card to let us know which provider group you have chosen. 3) Be automatically assigned to a new medical group and primary care physician by Anthem Blue Cross. If you wish to be automatically assigned to a new medical group and primary care physician, you do not need to contact Anthem Blue Cross. You will automatically be assigned to a new provider group and primary care physician effective <DATE OF TERMINATION>. If you have any questions regarding this notice, please contact Anthem Blue Cross Customer Care Department using the telephone number located on your membership card. If you have further concerns about your provider network, you are encouraged to contact the Department of Managed Health Care by telephone at its toll-free number HMO-2219, or at TDD number for the hearing impaired at , or online at Your health care needs are very important to us, and we are committed to providing you with exceptional service. Please be assured that your health care coverage will not be interrupted and that your selection will not result in a change to your covered benefits. Si usted necesita asistencia en español, por favor llame al Departamento de Servicio al Cliente de Anthem Blue Cross al número de telefono gratis en su tarjeta de identificacion Sincerely, Anthem Blue Cross 14

15 Termination of Provider: Enrollee Notification Attachment E Sample Enrollee Letter PPO Physician Termination Member name Address C, S, Z, Date: Dear Prudent Buyer Plan member: The purpose of this letter is to advise you of the status change of a provider who has rendered health care services to you or members of your family. Regarding: Cancel Date: (Dr s name) As of the date indicated, the above-named physician will no longer be a participant in the Prudent Buyer Plan. Please be aware that you or any member of your family covered under the Prudent Buyer Plan has the option to continue to seek services from this physician. However, eligible benefits will be paid at the non-participating (outof-network) level and the physician will no longer be contractually obligated not to balance bill you. You or any family member covered under the Prudent Buyer Plan may have the right to continue with a nonparticipating provider at in-network benefit levels if you or the member are undergoing a course of treatment for one of the following conditions: an acute condition, a serious chronic condition, a pregnancy, a terminal illness, care of a newborn child (0 to 36 months) or performance of a surgery/procedure that has been authorized by Anthem Blue Cross as part of a documented course of treatment and has been recommended to occur within 180 days of the above termination date. Members with a serious chronic condition and newborns may be allowed to continue accessing their non-participating provider until services are completed and a safe transfer can be arranged, not to exceed 12 months. Pregnant members and members with an acute condition or a terminal illness may be allowed to continue such access for the duration of the pregnancy, the acute condition or terminal illness. Please contact Anthem Blue Cross Customer Service using the toll-free number listed on your Prudent Buyer Plan I.D. card to request transition of care assistance. If you have further questions you are encouraged to contact the Department of Managed Health Care, which protects certain consumers, by telephone at its toll-free number HMO-2219, or at TDD number for the hearing impaired at , or online at If you wish to select another participating Prudent Buyer Plan physician, you may access Anthem Blue Cross Web site at click on the Members link, and follow Find a Doctor prompts or consult your Prudent Buyer Plan Directory of Participating Providers. You may also contact Anthem Blue Cross Customer Service at the (800) number listed on your I.D. card to determine your contractual benefit level for services of a nonparticipating physician, or for information relative to other available providers. We appreciate your continued membership in the Prudent Buyer Plan. Si usted necesita asistencia en español, por favor llame al Departamento de Servicio al Cliente de Anthem Blue Cross al número de telefono gratis en su tarjeta de identificacion Sincerely, (VP name) Network Management 15