Billing Manual for Community Care Network Providers

III.B.5b Termination with CauseAction to terminate a provider with cause may be initiated when Community Carebecomes aware of any of the following:Serious issue regarding the provider’s quality of care.Revocation or suspension of a provider’s license or other legal credential authorizingthe provider to practice in any state or jurisdiction.Revocation or suspension of Drug Enforcement Agency (DEA) registration orControlled Dangerous Substance (CDS) certificate.Professional review action by any state or jurisdiction issuing a professional licenseor any federal agency, professional organization, or other identified regulatoryorganization.Contractual violation, including, but not limited to:• Breach of confidentiality.• Failure to comply with terms of a corrective action plan.• Material misrepresentation of information on the provider application forcredentialing/recredentialing or assessment/reassessment.• Conviction of a felony.• Cancellation or failure to renew or maintain professional liability insurance in theamounts acceptable to Community Care.The Provider is notified in writing via certified mail of the action to initiate terminationwith cause, including the reason for this action. Included in this correspondence is anexplanation of the process to request an appeal of the decision to terminate with cause(See following Section III.B.6).III.B.6 Notification and Process to Appeal Adverse Determinations RegardingNetwork ParticipationProviders are notified in writing of any determination affecting their continuedparticipation in the provider network, including credentialing/recredentialing orassessment/reassessment, suspension of new referrals, or termination from thenetwork. This written notification will include the reason for the decision and anexplanation of the appeal process, if any.The appeal process is as follows:Within 30 days from the date of the notification, the provider must send a letter, fax,or email to the Community Care Chief Medical Officer (CMO) to request to appealthe decision.The CMO will schedule an Appeal Committee meeting to be held within 30 days ofreceiving the provider’s request.The provider will be informed of the date, time, and place of the meeting as well asthe provider’s right to be present at the hearing, to be represented by an attorney, toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 65