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The Medical Director will initiate an immediate review \ action under the following circumstances:

  • When it appears to the Medical Director that the participating practitioner is engaging in conduct that is outside the professional standard of care.

  • The participating practitioner is about to or has lost his ability to practice medicine in the State of New York or any other state, whether through revocation or suspension of license, whether or not stayed, through physical, mental disability or conviction of a crime, or surrender of license or inactivation of license.

  • The participating practitioner fails to comply with Atlantis Health Plan's policies, procedures, rules, regulations, terms and conditions of the participating practitioner agreement.

  • The participating practitioner is non-compliant with recredentialing quality initiatives, quality assurance and/or improvement, peer review, copying and forwarding of member's medical records, utilization review, continuing education and other programs that may be established by Atlantis Health Plan to promote high standards of health care for its members.

  • If a practitioner submits fraudulent claims.

    When Atlantis Health Plan determines to terminate a contract with a provider, the notification of the proposed termination by Atlantis to the health care professional will be sent via certified mail, return receipt requested. The notice to terminate shall contain:

    1. The reasons for the proposed action;
    2. Notice that provider has the right to request a review hearing by a panel appointed by Atlantis Health Plan. The health care professional must request a hearing within thirty days of notification of the proposed termination, or lose the right to a hearing. The hearing date will be set within thirty days of notification of the plan by the health professional that he or she has requested a hearing.
No health care provider's contract will be terminated, or refused renewal , solely because the provider has:
  1. advocated on behalf of a member.
  2. filed a complaint against Atlantis Health Plan.
  3. appealed a decision of the Plan
  4. provided information or filed a report pursuant to PHL 4406-c regarding prohibitions of plans.
  5. requested a hearing or review pursuant to PHL 4406-d and following sections.
The procedures for the proposed hearing are as follows:
  1. The hearing panel will be comprised of three persons appointed by Atlantis Health Plan. At least one panel member shall be a clinical peer in the same discipline or same specialty as the person under review. The panel may consist of more than three members, provided the number of clinical peers constitutes one-third or more of the total membership.
  2. The hearing panel shall render a decision in a timely manner. Decisions will include one of the following and will be provided in writing to the health care professional: reinstatement, provisional reinstatement with conditions set forth by Atlantis Health Plan, or termination.
  3. A decision by the hearing panel to terminate a health care professional shall be communicated to the health care professional within thirty (30) days of the panel's decision.
  4. Atlantis Health Plan shall permit a member to continue an on-going course of treatment for a transition period of up to ninety (90) days and postpartum care, subject to provider agreement.
  5. In no event shall termination be effective earlier than 60 days from receipt of the notice of termination.
By contractual agreement, the practitioner has thirty (30) days to request an appeal of the decision.

If the practitioner does appeal the decision within the required thirty (30) days, the following will take place:

  1. The practitioner is notified of receipt of the request for appeal.
  2. The practitioner's appeal is brought before the Appeals Committee within thirty (30) days.
  3. The physician has the opportunity to be present at the Appeals Committee hearing.
  4. The physician has the opportunity to be represented by legal counsel.
  5. The provider is notified of the decision of the Appeals Committee in writing within thirty (30) days of the hearing date.
Atlantis Health Plan as an Article 44 Health Maintenance Organization has a duty to report specific actions taken in relation to a provider. The mandatory reporting includes the following:
  1. Termination of a health care provider contract for reasons relating to alleged mental or physical impairment, misconduct or impairment of member safety or welfare;

  2. The voluntary or involuntary termination of a contract or other affiliation with such organization to avoid the imposition of disciplinary measures;

  3. The termination of a health care provider contract in the case of a determination of fraud or in a case of imminent harm to a patient health.

    The reports will contain the provider's full name, medical license number, address, date of event/incident, description of actions taken by the Health Plan including date of termination of a contract or withdrawal; and contact persons at the Atlantis Health Plan.

    Pursuant to Section 230 of the Public Health Law for the State of New York, any remedial action lasting more than thirty (30) days and/or termination will be reported to the Office of Professional Discipline or the Office of Professional Medical conduct and the National Practitioner Data Bank. In addition, Atlantis Health Plan is legally obligated to report to the appropriate professional disciplinary agency within sixty (60) days of obtaining knowledge of any information that reasonably appears to show that a health professional is guilty of professional misconduct.

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