Notice to beneficiaries when a specialty provider leaves network
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Template communication outlining options and processes for members whose specialty or ancillary provider is terminating from the plan network; affects beneficiaries currently receiving care from the departing provider and plan/PPG staff administering continuity of care.
No material clinical or coverage changes in this revision.
Continuity and Transfer of Care
Continuity and transfer of care criteria
Stance on member coverage and continuity when a provider terminates:
Based on statement that benefits do not change.
Continuation requests handled case-by-case and require prior authorization.
Maximum standard continuation period and extension criteria.
Method for requesting continuation and decision authority.
Provider Actions and Authorization
Continuity of care requires prior authorization and case-by-case review
All requests for continuity of care will be reviewed individually and must receive prior authorization before continuation is approved.
- Continuation may be approved for up to ninety (90) days; extensions possible if medically necessary, postpartum for pregnancy-related conditions, or until care can be safely transferred.
- To request continuation, members must call Health Plan Customer Service (TTY users use 711 or plan TTY number) or contact their PPG Primary Care Physician; the plan or PPG Medical Director will determine management in consultation with the terminated provider.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.