Common use of PROVIDER CONTRACT AND SUBCONTRACT TERMINATION Clause in Contracts

PROVIDER CONTRACT AND SUBCONTRACT TERMINATION. A. The contractor shall comply with all the provisions of the New Jersey HMO regulations at N.J.A.C. 8:38 et seq. regarding provider termination, including but not limited to 30 day prior written notice to enrollees and continuity of care requirements. B. The contractor shall notify DMAHS at least 30 days prior to the effective date of suspension, termination, or voluntary withdrawal of a provider or subcontractor from participation in this program. If the termination was "for cause," the contractor's notice to DMAHS shall include the reasons for the termination. 1. Provider resource consumption patterns shall not constitute "cause" unless the contractor can demonstrate it has in place a risk adjustment system that takes into account enrollee health-related differences when comparing across providers. 2. The contractor shall assure immediate coverage by a provider of the same specialty, expertise, or service provision and shall submit a new contract with a replacement provider to DMAHS within 30 days of being finalized. C. If a primary care provider ceases participation in the contractor's organization, the contractor shall provide written notice at least thirty (30) days from the date that the contractor becomes aware of such change in status to each enrollee who has chosen the provider as their primary care provider. If an enrollee is in an ongoing course of treatment with any other participating provider who becomes unavailable to continue to provide services to such enrollee and contractor is aware of such ongoing course of treatment, the contractor shall provide written notice within fifteen days from the date that the contractor becomes aware of such unavailability to such enrollee. Each notice shall also describe the procedures for continuing care and choice of other providers who can continue to care for the enrollee. D. All provider contracts shall contain a provision that states that the contractor shall not terminate the contract with a provider because the provider expresses disagreement with a contractor's decision to deny or limit benefits to a covered person or because the provider assists the covered person to seek reconsideration of the contractor's decision; or because a provider discusses with a current, former, or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether covered by the contractor or not, policy provisions of a plan, or a provider's personal recommendation regarding selection of a health plan based on the provider's personal knowledge of the health needs of such patients. Nothing in this Article shall be construed to prohibit the contractor from: 1. Including in its provider contracts a provision that precludes a provider from making, publishing, disseminating, or circulating directly or indirectly or aiding, abetting, or encouraging the making, publishing, disseminating, or circulating of any oral or written statement or any pamphlet, circular, article, or literature that is false or maliciously critical of the contractor and calculated to injure the contractor; or 2. Terminating a contract with a provider because such provider materially misrepresents the provisions, terms, or requirements of the contractor.

PROVIDER CONTRACT AND SUBCONTRACT TERMINATION. A. The contractor shall comply with all the provisions of the New Jersey HMO regulations at N.J.A.C. 8:38 11:24 et seq. regarding provider termination, including but not limited to the 30 business day prior written notice to enrollees regarding termination or withdrawal of PCPs and any other physician or provider from which the member is receiving a course of treatment; continuity of care requirements; and, in the case of a hospital termination/non-renewal, written notification within the first fifteen (15) business days of the four month extension to all contracted providers and members who reside in the county in which the hospital is located or in an adjacent county within the contractor’s service area. B. The contractor shall notify DMAHS at least 30 days prior to the effective date upon request of suspension, termination, or voluntary withdrawal of a provider or subcontractor from participation in this program. If the termination was "for cause," the contractor's notice to DMAHS shall include the reasons for the termination. 1. Provider resource consumption patterns shall not constitute "“cause" ” unless the contractor can demonstrate it has in place a risk adjustment system that takes into account enrollee health-related differences when comparing across providers. 2. The contractor shall assure immediate coverage by a provider of the same specialty, expertise, or service provision and shall submit a new contract with a replacement provider to DMAHS within 30 45 days prior to the effective date. 3. The contractor shall, on request, provide DMAHS with periodic updates and information pertaining to specific potential provider terminations, including status of being finalizedrenegotiation efforts. C. If a primary care provider ceases participation in the contractor's organization, the contractor shall provide written notice at least thirty (30) days from the date that the contractor becomes aware of such change in status to each enrollee who has chosen the provider as their primary care provider. If an enrollee is in an ongoing course of treatment with any other participating provider who becomes unavailable to continue to provide services to such enrollee and contractor is aware of such ongoing course of treatment, the contractor shall provide written notice within fifteen days from the date that the contractor becomes aware of such unavailability to such enrollee. Each notice shall also describe the procedures for continuing care and choice of other providers who can continue to care for the enrollee. D. All provider contracts shall contain a provision that states that the contractor shall not terminate the contract with a provider because the provider expresses disagreement with a contractor's decision to deny or limit benefits to a covered person or because the provider assists the covered person to seek reconsideration of the contractor's decision; or because a provider discusses with a current, former, or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether covered by the contractor or not, policy provisions of a plan, or a provider's personal recommendation regarding selection of a health plan based on the provider's personal knowledge of the health needs of such patients. Nothing in this Article shall be construed to prohibit the contractor from: 1. Including in its provider contracts a provision that precludes a provider from making, publishing, disseminating, or circulating directly or indirectly or aiding, abetting, or encouraging the making, publishing, disseminating, or circulating of any oral or written statement or any pamphlet, circular, article, or literature that is false or maliciously critical of the contractor and calculated to injure the contractor; or 2. Terminating a contract with a provider because such provider materially misrepresents the provisions, terms, or requirements of the contractor.

PROVIDER CONTRACT AND SUBCONTRACT TERMINATION. A. The contractor shall comply with all the provisions of the New Jersey HMO regulations at N.J.A.C. 8:38 et seq. regarding provider termination, including but not limited to the 30 business day prior written notice to enrollees regarding termination or withdrawal of PCPs and any other physician or provider from which the member is receiving a course of treatment; continuity of care requirements; and, in the case of a hospital termination/non-renewal, written notification within the first fifteen (15) business days of the four month extension to all contracted providers and members who reside in the county in which the hospital is located or in an adjacent county within the contractor’s service area. B. The contractor shall notify DMAHS at least 30 45 days prior to the effective date of suspension, termination, or voluntary withdrawal of a provider or subcontractor from participation in this program. If the termination was "“for cause," ” the contractor's ’s notice to DMAHS shall include the reasons for the termination. 1. Provider resource consumption patterns shall not constitute "“cause" ” unless the contractor can demonstrate it has in place a risk adjustment system that takes into account enrollee health-related differences when comparing across providers. 2. The contractor shall assure immediate coverage by a provider of the same specialty, expertise, or service provision and shall submit a new contract with a replacement provider to DMAHS within 30 45 days prior to the effective date. 3. The contractor shall, on request, provide DMAHS with periodic updates and information pertaining to specific potential provider terminations, including status of being finalizedrenegotiation efforts. C. If a primary care provider ceases participation in the contractor's ’s organization, the contractor shall provide written notice at least thirty (30) days from the date that the contractor becomes aware of such change in status to each enrollee who has chosen the provider as their primary care provider. If an enrollee is in an ongoing course of treatment with any other participating provider who becomes unavailable to continue to provide services to such enrollee and contractor is aware of such ongoing course of treatment, the contractor shall provide written notice within fifteen days from the date that the contractor becomes aware of such unavailability to such enrollee. Each notice shall also describe the procedures for continuing care and choice of other providers who can continue to care for the enrollee. D. All provider contracts shall contain a provision that states that the contractor shall not terminate the contract with a provider because the provider expresses disagreement with a contractor's ’s decision to deny or limit benefits to a covered person or because the provider assists the covered person to seek reconsideration of the contractor's ’s decision; or because a provider discusses with a current, former, or prospective patient any aspect of the patient's ’s medical condition, any proposed treatments or treatment alternatives, whether covered by the contractor or not, policy provisions of a plan, or a provider's ’s personal recommendation regarding selection of a health plan based on the provider's ’s personal knowledge of the health needs of such patients. Nothing in this Article shall be construed to prohibit the contractor from: 1. Including in its provider contracts a provision that precludes a provider from making, publishing, disseminating, or circulating directly or indirectly or aiding, abetting, or encouraging the making, publishing, disseminatingare eligible to enroll on a voluntary basis. Persons falling into a category under Article 5.3.2 may be eligible for enrollment exemption, or circulating of any oral or written statement or any pamphlet, circular, article, or literature that is false or maliciously critical of subject to the contractor and calculated to injure the contractor; or 2. Terminating a contract with a provider because such provider materially misrepresents the provisions, terms, or requirements of the contractorDepartment’s review.