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PCP Request to Discharge a Member

HealthPlus requires that primary care physicians (PCP) accept and see patients according to the terms of their contractual agreements. Inasmuch as a member chooses his or her primary care physician, HealthPlus discourages the discharge of any patient without full discussion and an attempt to resolve issues.

We realize, however, that there may be times when the physician/patient relationship cannot be preserved. HealthPlus requires patient discharge requests be nondiscriminatory and consistent with the office policy for all of the physician’s patients.

Required HealthPlus Approvals

All requests to discharge a HPM member must include detailed documentation describing the facts surrounding the discharge. The Physician Group Medical Director is responsible for reviewing the physician’s request to discharge a patient and related documentation (if applicable).

Please do not communicate information to the patient until you have received formal notification from HealthPlus.

The HealthPlus Medical Director will evaluate and determine whether to approve the patient discharge request, based upon documented facts provided by the PCP.

Reasons for a member discharge may include, but are not limited to:

  • The member’s age is inconsistent with the PCP’s practice.
  • The member is unwilling to use affiliated providers for specialty care.
  • The member did not want to receive services through the PCP’s affiliated hospital system.
  • The member has an unpaid financial debt with the PCP that is over 90 days outstanding and attempts have been made by the PCP to collect the outstanding debt.
  • The PCP was listed as not accepting new patients in the HealthPlus provider directory at the time of open enrollment or at the time the member made the selection.
  • The member is non-compliant with recommended treatment, resulting in excessive Emergency Department and Urgent Care usage.
  • The member has missed numerous appointments without providing notification (defined as three (3) no-shows within a 12-month period).
  • The member has permanently moved outside of the HealthPlus coverage area.
  • A breakdown in the physician-patient relationship has occurred including, but not limited to, threatening behavior. A description of the breakdown in the relationship must be clearly documented and submitted with the discharge request.

Approval of Charge

If the request for discharge is approved, the HealthPlus Medical Director will notify the health system partner of the agreed change and the PCP will provide written notification of the discharge, to the member. The PCP is required to provide/or direct emergency and urgent care services to the member for at least 30 days following the approval date of the discharge.

Member discharges approved by the HealthPlus Medical Director are effective based on the following time frames:

  • Where approval occurs prior to the 15th of the month, the effective date will be the first of the following month.
  • Where approval occurs after the 15th of the month, the effective date is the first of the month following a 30-day waiting period. This period is necessary to allow sufficient time to notify the PCP of the approval of the discharge, for the PCP to notify the patient in writing, for a new PCP to be selected by the member, and for transferring of the member’s medical records to the new PCP.

Note: It is imperative that the patient discharge request be submitted to the HealthPlus Medical Director by Provider Network Management within seven (7) business days to ensure that the member receives continuous access to physicians and appropriate health care.

To request the discharge of a patient, the PCP must complete a Member Discharge/Termination Request Form . Fax the completed form to the Provider Network Management Department at (810) 230-2081 or (989) 799-8494.

Please contact the Provider Network Department with additional questions at: (810) 230-2172.