CMS Pub. 100-16, ch. 6, § 60.4

Advance Notice for Suspension or Termination

An MA organization and a contracting provider must provide at least 60 days written

notice to each other before terminating a contract without cause.

Reporting of Suspensions or Terminations Due to Quality Deficiencies

An MA organization that suspends or terminates a contract with a physician because of

deficiencies in the quality of care must give written notice of that action to licensing or

disciplinary bodies or to other appropriate authorities.

Suspension, Termination, or Nonrenewal of Physician Contracts

Specific requirements for an MA organization that operates a coordinated care plan or

network MSA plan providing benefits through contracting physicians and that suspends,

terminates, or non-renews a physician’s contract are as follows:

1. The MA organization must give the affected physician written notice of the

reasons for the action, including, if relevant, the standards and profiling data used

to evaluate the physician and the numbers and mix of physicians needed by the

MA organization.

2. The MA organization must allow the physician to appeal the action, and give the

physician written notice of his/her right to a hearing and the process and timing

for requesting a hearing.

3. The MA organization must ensure that the majority of the hearing panel members

are peers of the affected physician.

Preamble to the February 17, 1999, final rule responded to public comment that notice

and appeal requirements apply regardless of whether suspension or termination of the

physician contract is due to quality deficiencies or not, unless the physician voluntarily

agreed to leave the organization’s network. In addition, it was clarified that these

requirements apply to nonrenewal of contracts.

An MA organization that operates an MA plan through subcontracted physician groups

must provide that these procedures apply equally to physicians within those

subcontracted groups.

(Source: 42 CFR 422.202(c) and (d) and preamble of February 17, 1999, rule.)