DENTAL POLICY:
Dental Provider Termination Involuntary
EFFECTIVE DATE:
August 15, 2018
LAST REVIEWED DATE:
June 12, 2024
LAST REVISED DATE:
June 12, 2024
PURPOSE:
To outline the process for the termination of a provider and to arrange for continuity of care for a member serviced by the provider in the event that the Provider, Horizon HMO and/or Horizon NJ Health (HNJH) terminates the practitioner agreement.
SCOPE AND APPLICABILITY:
This policy applies to the termination of all Primary Care Dentists, (PCD), Managed Care Long Term Services and Support (MLTSS) Traditional and Non-Traditional Providers. Horizon NJ Health recognizes the need to ensure that all provider information is accurately reflected in our databases, including terminations. The Professional Contracting and Servicing Department is responsible for ensuring provider terminations are implemented accurately and timely in accordance with contractual obligations and consistent with Regulatory requirements.
This policy applies to the Medicaid/NJ Family Care and Fully Integrated Dual Eligible Special Needs (“FIDE-SNP”) plans issued and/or administered by Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey and/or its affiliates, including Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health (collectively “Horizon”).
POLICY:
Horizon NJ Health may immediately terminate the contractual agreement with a provider for any of the following circ*mstances, which would qualify as fraud, breach of contract, imminent danger to the member or public health, safety and welfare:
Failure to provide notice of any indictment or conviction of a crime.
Failure to maintain current, valid, unrestricted license(s) to practice medicine and certification to prescribe medication.
Any State or Federal sanction and/or debarment.
Any cause, which Horizon NJ Health determines, may interfere with patient care or jeopardize the welfare of members or Horizon NJ Health.
Materially breaches the provider contract/subcontract.
Violates state or federal law.
Has certification suspended or revoked by the Department of Banking and Insurance (DOBI), Department of Health and Senior Services (DHSS) and /or federal agency or is federally debarred or excluded from federal procurement and non-procurement contracts.
Failure to abide by the terms and conditions of the Contractual Agreement or any policies, rules and procedures established or which Horizon NJ Health or Horizon HMO may establish.
In accordance with the NJ Family Care contract, Horizon HMO and/or Horizon NJ Health may terminate the contractual agreement with a provider, with a ninety (90) day advance notice of any of the following reasons:
Any material misstatement or omissions from the application or renewal of such application or any other information provided.
Takes any action that threatens the fiscal integrity of the Medicaid program.
Becomes insolvent or falls below the minimum net worth requirements.
Seeks protection or has a proceeding brought against its involuntary, under the US Bankruptcy Code.
Upon receipt of notification from the State of New Jersey and /or HNJH of debarment or immediate termination, the practitioner shall immediately cease providing services and treatment to Horizon NJ Health members. Services shall not be authorized for the affected provider.
SANCTIONS:
Horizon Government Program Health Service may be subject to the Sanctions and/or Liquated Damage Provisions of the Medicaid Contract, Specifically, Articles 7.15 and 7.16.
EXCEPTIONS:
Departmental policies as defined within are not subject to this policy and procedural processes.
PROCEDURAL WORKFLOW:
A copy of the termination notification letter from Horizon Dental will be forwarded from the Dental Director or designee within five (5) business days of receipt.
The Dental Director/designee and/or Legal Counsel will approve the termination letter and Horizon will mail a certified letter to the practitioner notifying of the immediate termination within five (5) business days. This letter will address the fair hearing procedure as set forth in the Termination Policy and request the practitioner to identify any member through reporting that is in need of continued dental care.
Primary Care Dentist (PCD) Termination effective date will be the date provided by the Dental Director, designee or the Credentialing Committee Determination Date.
SKYGEN USA will forward a copy of the certified letter via mail within SKYGEN USA Provider Relations within two (2) business days of mailing.
SKYGEN USA will forward a copy of the certified letter to SKYGEN USA Provider Relations within one (1) business day of receipt.
SKYGEN USA Provider Relations Department will terminate the provider at all locations in the provider database and forward the termination request along with panel transfer instructions for termination in the claim system within two (2) business days.
SKYGEN USA Provider Relations Department will change the status of the provider from participating to nonparticipating in the claims systems using the correct termination date and transfer all members to the succeeding PCD within two (2) business days of notification from Provider File.
SKYGEN USA will notify the members of the PCD termination immediately. Members are notified in writing and when appropriate via telephone.
Horizon NJ Health will no longer list the PCD in the online provider directory or in the marketing and provider directories.
The PCD immediately removes all indication of their participation in the Horizon NJ Health Network.
Department will be notified that the provider is listed as nonparticipating via the weekly termination report.
Primary Care Dentist (PCD): Termination Failure to Notify Plan, No longer with Dental Group.
SKYGEN USA Provider Relations Department receives termination notification from Dental Group: Primary Care Dentist (PCD) no longer with practice or group
SKYGEN USA Provider Relations will send confirmation notification to Dental Group within three business three business days of receipt of notification confirming receipt of termination request.
Primary Care Dentist (PCD) termination effective date will be the receipt date of the notification.
SKYGEN USA Provider Relations will terminate provider at all locations in the Provider Data Management System.
SKYGEN USA Provider Relations will run a utilization report, not to exceed 12 months (from the date the PCD left the practice up to the notification date).
- If no utilization found, skip to step 6.
- If utilization found, refer to the table below:
If Then No, FWA determined - If group practice, skip to step 6.
- If solo practitioner, SKYGEN USA will notify member of PCD termination.
FWA determined SKYGEN USA will refer to HNJH Dental Director for SIU referral for recoupment: - If group practice, skip to step 6.
- If solo practitioner, SKYGEN USA will notify members of PCD termination
SKYGEN USA Provider Relations will change the status of the provider from participating to nonparticipating in the claims system.
Horizon NJ Health will no longer list PCD in the online provider directory or in the marketing and provider directories.
Horizon Provider Files Department will be notified that the provider is listed as nonparticipating via the weekly termination report.
REFERENCES:
Regulatory References
NJ Medicaid Managed Care Contract, 31C.273 Annual Review of Member Benefits Policies New Jersey Administrative Code 10:56, N.JAC 10:56 13:30 NCQA Current Standards and Guidelines for Accreditation of Health Plans
Policy References
Dental Provider Termination Policy Involuntary
REVISION HISTORY:
06/12/2024: Reformatted policy content for posting within this new Dental Services subsection.
43C-016-06122024
