Contractor Initiated Disenrollment Clause Samples
Contractor Initiated Disenrollment a) The Contractor may initiate an involuntary disenrollment if the Enrollee engages in conduct or behavior that seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee.
b) Consistent with 42 CFR 438.56 (b), the Contractor may not request disenrollment because of an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's special needs (except where continued enrollment in the Contractor's plan seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees).
c) The Contractor must make a reasonable effort to identify for the Enrollee, both verbally and in writing, those actions of the Enrollee that have interfered with the effective provision of covered services as well as explain what actions or procedures are acceptable.
d) The Contractor shall give prior verbal and written notice to the Enrollee, with a copy to the LDSS, of its intent to request disenrollment. The written notice shall advise the Enrollee that the request has been forwarded to the LDSS for review and approval. The written notice must include the mailing address and telephone number of the LDSS.
e) The Contractor shall keep the LDSS informed of decisions related to all complaints filed by an Enrollee as a result of, or subsequent to, the notice of intent to disenroll.
f) The LDSS will review each Contractor initiated disenrollment request in accordance with the provisions of this Section. Where applicable, the LDSS may consult with local mental health and substance abuse authorities in the district when making the determination to approve or disapprove a Contractor initiated disenrollment request.
g) The LDSS will render a decision within fifteen (15) days of receipt of the fully documented request for disenrollment. Final written determination will be provided to the Enrollee and the Contractor. If the LDSS determination upholds the Contractor's request to disenroll, the LDSS's written determination must inform the Enrollee of the Effective Date of Disenrollment and include a notice of rights to a fair hearing. Should an SECTION 8 (DISENROLLMENT) October 1, 2004 8-5 Enrollee request a fair hearing as a result of the LDSS determina...
Contractor Initiated Disenrollment a) The Contractor must notify the LDSS and initiate an Enrollee's Disenrollment from the Contractor's Medicaid Advantage Product in the following cases:
i) A change in residence makes the Enrollee ineligible to be a member of the plan;
ii) The Enrollee disenrolls from the Contractor's Medicare Advantage Product as defined in this Agreement;
iii) The Enrollee dies;
iv) The Enrollee's status changes such that he/she is no longer eligible to participate in Medicaid Advantage as described in Section 5 of this Agreement.
b) The Contractor may initiate an Enrollee's disenrollment from the Contractor's Medicaid Advantage Product in the following cases:
i) The Enrollee engages in conduct or behavior that seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee.
ii) The Enrollee provides fraudulent information on an enrollment form or the Enrollee permits abuse of an enrollment card in the Medicaid Advantage Program except when the Enrollee is no longer eligible for Medicaid and is in his/her Guaranteed Eligibility period.
iii) Consistent with 42 CFR 438.56 (b), the Contractor may not request Disenrollment because of an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's special needs (except where continued enrollment in the Contractor's plan seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees).
Contractor Initiated Disenrollment a) The Contractor may initiate an involuntary Disenrollment if an Enrollee engages in conduct or behavior that seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee.
b) Consistent with 42 CFR§ 438.56 (b), the Contractor may not request Disenrollment because of an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's special needs (except where continued Enrollment in the Contractor's MMC (DISENROLLMENT) October 1, 2005
Contractor Initiated Disenrollment a) The Contractor may initiate an involuntary disenrollment if the Enrollee engages in conduct or behavior that seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee.
b) Consistent with 42 CFR 438.56 (b), the Contractor may not request disenrollment because of an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's special needs (except where continued enrollment in the Contractor's plan seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees).
c) The Contractor must make a reasonable effort to identify for the Enrollee, both verbally and in writing, those actions of the Enrollee that have interfered with the effective provision of covered services as well as explain what actions or procedures are acceptable.
Contractor Initiated Disenrollment. Contractor may recommend to the State the disenrollment of any Member in the event of a breakdown in the “doctor-patient relationship” which makes it impossible for Contractor’s Contracting Providers to render services adequately to a Member. Except in cases of violent behavior or fraud, Contractor shall make a significant effort to resolve the problem with the Member through avenues such as reassignment of PCP, education, or referral to services (such as mental health or substance abuse programs), before requesting a Contractor-initiated disenrollment. In cases of Contractor-initiated disenrollment, Contractor must submit to the State a written request for disenrollment with supporting documentation based on the breakdown of Contractor Member relationship. Contractor-initiated disenrollments must be prior approved by DHS and will be considered only under the following circumstances:
Contractor Initiated Disenrollment a) The Contractor may initiate an involuntary Disenrollment if an Enrollee engages in conduct or behavior that seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee.
b) Consistent with 42 CFR Section 438.56 (b), the Contractor may not request Disenrollment because of an adverse change in the Enrollee's health status, or because of the Enrollee's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee's special needs (except where continued Enrollment in the Contractor's MMC SECTION 8 (DISENROLLMENT) October 1, 2005 8-3 or FHPlus product seriously impairs the Contractor's ability to furnish services to either the Enrollee or other Enrollees).
c) Contractor initiated Disenrollments must be carried out in accordance with the requirements and timeframes described in Appendix H of this Agreement.
d) Once an Enrollee has been disenrolled at the Contractor's request, he/she will not be re-enrolled with the Contractor's MMC or FHPlus product unless the Contractor first agrees to such re-enrollment.