Access to Care and Delivery System > Removal of a Member From a PCP Panel / Discontinuation of Specialty Care Services
A PCP or Primary Caregiver may request removal of a member from his/her panel or a specialty care practitioner may request to discontinue treating a member if:
- The member repeatedly fails to keep appointments
- The member repeatedly disregards the practitioner's medical advice
- The member exhibits continual abusive behavior toward the practitioner or his/her office staff
- The practitioner is unable to establish a mutually beneficial relationship with the member
The practitioner should provide at least 90 days prior written notice to Provider Relations that he/she will not continue as the member's physician. Provider Relations will coordinate with the Customer Service department to notify the member.
Glossary terms found on this page:
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.