Provider Manual

NON-RENEWAL OF PROVIDER AGREEMENT

Carelon practitioner/facility agreements are effective from the date specified on the execution page and continue in effect for one year and will automatically renew for additional one-year terms, unless and until either party notifies the other party 30 days prior to the renewal date that the agreement will not be renewed.

The following are types of disenrollments:

  • Voluntary
  • Involuntary
  • Termination upon breach

Voluntary

Either Carelon or a participating provider may terminate the provider agreement without cause upon 60 days written notice.

However, Carelon will not disenroll a provider on the grounds that the provider:

  • Advocated on behalf of a member;
  • Filed a complaint against Carelon;
  • Appealed a decision of Carelon; or
  • Requested a review or challenged a decision of Carelon to terminate the practitioner or facility from the Carelon network.

Involuntary Termination or Suspension

Under the contract, the provider may be terminated or suspended immediately in the event of any of the following:

  • Suspension or revocation of provider’s license or credentials to provide any covered services provider was previously licensed to provide;
  • Provider’s indictment, arrest or conviction of a felony, or any criminal charge related to the rendering of services of the type contemplated by the practitioner/facility agreement;
  • The termination or lapse of the insurance requirements specified in the practitioner/facility agreement;
  • Provider’s failure to remain in compliance with Carelon licensure and credentialing standards;
  • Provider’s action or inaction that, in Carelon’s sole discretion, results in a threat to the health, well-being or best interest of a member.

Termination Upon Breach

Either Carelon or a participating provider may terminate the practitioner/facility agreement by giving the other party 30 days written notice of a breach by such other party of its obligation under the agreement. Any such termination shall be effective if the other party has failed to cure the breach within 30 days following receipt of such written notice.