Common use of NETWORK CHANGES Clause in Contracts

NETWORK CHANGES. 4.8.18.1 The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as: · A decrease in the total number of PCPs by more than five percent (5%); · A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; · A loss of a hospital in an area where another contracted hospital of equal service ability is not available within thirty (30) miles; or · Other adverse changes to the composition of the network, which impair or deny the Members’ or P4HB Participants adequate access to In-Network Providers. 4.8.18.2 The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies. 4.8.18.3 If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability. 4.8.18.5 These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, notice shall be issued immediately upon the Contractor becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 4.8.17.1 The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as: · : 4.8.17.1.1 A decrease in the total number of PCPs by more than five percent (5%); · ; 4.8.17.1.2 A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; · ; 4.8.17.1.3 A loss of a hospital in an area where another contracted CMO plan hospital of equal service ability is not available within thirty (30) miles; or · or 4.8.17.1.4 Other adverse changes to the composition of the network, network which impair or deny the Members’ or P4HB Participants adequate access to In-Network Providers. 4.8.18.2 4.8.17.2 The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies. 4.8.18.3 4.8.17.3 If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 4.8.17.4 If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability. 4.8.18.5 4.8.17.5 These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, circumstances notice shall be issued immediately upon the Contractor becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 1. The Contractor Health Plan shall notify DCH the Agency within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider Health Plan network. A significant change is defined as: · : a. A decrease in the total number of PCPs by more than five percent (5%); · ; b. A loss of all Providers Participating Specialists in a specific specialty where another Provider Participating Specialist in that specialty is not available within sixty (60) miles; · minutes; c. A loss of a hospital Hospital in an area where another contracted hospital Health Plan Hospital of equal service ability is not available within thirty (30) milesminutes; or · or d. Other adverse changes to the composition of the network, network which impair or deny the Members’ or P4HB Participants Enrollee's adequate access to In-Network Providers. 4.8.18.2 2. The Contractor Health Plan shall have procedures to address changes in the health plan Provider Health Plan network that negatively affect the ability of Members or P4HB Participants Enrollees to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant Enrollee access to services may be grounds for Contract termination or State Agency determined remediessanctions. 4.8.18.3 3. If a PCP ceases participation in the Contractor’s Provider network Health Plan network, the Contractor Health Plan shall send written notice to the Members and P4HB Participants Enrollees who have chosen the Provider as their PCP. This notice shall be issued no less than thirty ninety (3090) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 a. If a Member or P4HB Participant an Enrollee is in a prior authorized Prior Authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor Health Plan shall notify the Member or P4HB Participant Enrollee in writing within ten (10) Calendar Days from the date the Contractor Health Plan becomes aware of such unavailability. 4.8.18.5 b. These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members Enrollees due to illness, a Provider dies, the Provider moves from the Service Region Area and fails to notify the ContractorHealth Plan, or when a Provider fails Credentialingcredentialing. Under these circumstances, notice shall be issued immediately upon the Contractor Health Plan becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 1. The Contractor Health Plan shall notify DCH the Agency within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider Health Plan network. A significant change is defined as: · : a. A decrease in the total number of PCPs by more than five percent (5%); · ; b. A loss of all Providers Participating Specialists in a specific specialty where another Provider Participating Specialist in that specialty is not available within sixty (60) miles; · minutes; c. A loss of a hospital Hospital in an area where another contracted hospital Health Plan Hospital of equal service ability is not available within thirty (30) milesminutes; or · or d. Other adverse changes to the composition of the network, network which impair or deny the Members’ or P4HB Participants Enrollee's adequate access to In-Network Providers. 4.8.18.2 2. The Contractor Health Plan shall have procedures to address changes in the health plan Provider Health Plan network that negatively affect the ability of Members or P4HB Participants Enrollees to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant Enrollee access to services may be grounds for Contract termination or State Agency determined remediessanctions. 4.8.18.3 If 3. The Health Plan shall make a PCP ceases participation in the Contractor’s Provider network the Contractor shall send good faith effort to give written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty of termination within fifteen (3015) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days days after receipt of a termination notice to each Enrollee who received his or issuance of the termination noticeher primary care from, or was seen on a regular basis by, a terminated provider. 4.8.18.4 a. If a Member or P4HB Participant an Enrollee is in a prior authorized Prior Authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor Health Plan shall notify the Member or P4HB Participant Enrollee in writing within ten (10) Calendar Days from the date the Contractor Health Plan becomes aware of such unavailability. 4.8.18.5 b. These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members Enrollees due to illness, a Provider dies, the Provider moves from the Service Region Area and fails to notify the ContractorHealth Plan, or when a Provider fails Credentialingcredentialing. Under these circumstances, notice shall be issued immediately upon the Contractor Health Plan becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as: · A decrease in the total number of PCPs by more than five percent (5%); · A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; · A loss of a hospital in an area where another contracted hospital of equal service ability is not available within thirty (30) miles; or · Other adverse changes to the composition of the network, which impair or deny the Members’ or P4HB Participants adequate access to In-Network Providers. 4.8.18.2 The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies. 4.8.18.3 If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability. 4.8.18.5 These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, notice shall be issued immediately upon the Contractor becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as: · : 4.8.18.1.1 A decrease in the total number of PCPs by more than five percent (5%); · ; 4.8.18.1.2 A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; · ; 4.8.18.1.3 A loss of a hospital in an area where another contracted hospital of equal service ability is not available within thirty (30) miles; or · or 4.8.18.1.4 Other adverse changes to the composition of the network, which impair or deny the Members’ or P4HB Participants adequate access to In-Network Providers. 4.8.18.2 The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies. 4.8.18.3 If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability. 4.8.18.5 These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, notice shall be issued immediately upon the Contractor becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ ' Provider network. A significant change is defined as: · : 4.8.18.1.1 A decrease in the total number of PCPs by more than five percent (5%); · Revised 5/19/2008 4.8.18.1.2 A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; · ; 4.8.18.1.3 A loss of a hospital in an area where another contracted hospital of equal service ability is not available within thirty (30) miles; or · or 4.8.18.1.4 Other adverse changes to the composition of the network, which impair or deny the Members’ or P4HB Participants ' adequate access to In-Network Providers. 4.8.18.2 The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies. 4.8.18.3 If a PCP ceases participation in the Contractor’s 's Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability. 4.8.18.5 These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, notice shall be issued immediately upon the Contractor becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.

NETWORK CHANGES. 4.8.18.1 The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as: · • A decrease in the total number of PCPs by more than five percent (5%); · • A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; · • A loss of a hospital in an area where another contracted hospital of equal service ability is not available within thirty (30) miles; or · • Other adverse changes to the composition of the network, which impair or deny the Members’ or P4HB Participants adequate access to In-Network Providers. 4.8.18.2 The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members or P4HB Participants to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member or P4HB Participant access to services may be grounds for Contract termination or State determined remedies. 4.8.18.3 If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members and P4HB Participants who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice. 4.8.18.4 If a Member or P4HB Participant is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member or P4HB Participant in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability. 4.8.18.5 These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances, notice shall be issued immediately upon the Contractor becoming aware of the circumstances. 4.8.18.6 Continuity of Care Plan is required to be submitted to DCH 60 days prior to anticipated mass Network changes (as defined in 4.8.18.1) that will impact membership.