Request for Member Reassignment Form

Complete this form to request that an Alliance member be reassigned to a new primary care provider (PCP).

Procedure to Request Member Reassignment

1. Make sure you have the appropriate reasons to request member reassignment.
   Appropriate reasons to request to reassign a member include:
   • Member fraud
   • Request for non-medically necessary medications
   • Violation of Medication Management Agreement
   • Abusive or disruptive behaviors
   • Ineffective relationship
   • Non-compliance with case management – The member refuses to comply with case management or your recommended treatment thereby endangering their health or significantly aggregating a medical condition.
   • Failure to keep scheduled appointments - Requires:
     • Three failures in a12-month period (please list specific dates).
     • Good faith efforts by office to contact and remind the patient and include documenting efforts, either in patient chart or written office procedure.
     • Narrative description of other factors, if appropriate.

   Inappropriate reasons to request reassignment include:

   • Minor disruptive or verbally inappropriate behavior to provider or staff.
   • The member’s disagreement with a provider’s recommended course of treatment, where such disagreement does not endanger the health of the member or significantly aggravate a medical condition. Members have the right to refuse treatment and obtain a second opinion
   • The member has filed a complaint regarding the provider or the provider’s office staff.
2. Send written notification to the member.
   The purpose of sending written notification is to advise the member that you are taking the steps necessary to begin the reassignment process with the Alliance. A letter must be sent for each member you seek to have reassigned (reassignment of one person from a family does not automatically reassign the entire family). You can find samples of letters to send to members in the Provider Services section of Form Library on the Alliance provider website at
   www.ccah- alliance.org/formlibrary.html. These samples are available in English, Spanish and Hmong.
3. Complete a Request for Member Reassignment form.
   A Request for Member Reassignment form must be completed for each member you seek to have reassigned (reassignment of one person from a family does not automatically reassign the entire family). The form is designed to allow a narrative description of events leading to your request. Be sure to give specific information (e.g., dates of missed appointments or an explanation of a patient’s abusive behavior, a copy of the Medication Management Agreement) as well as your efforts to correct the problem with the patient. Your request may be delayed or denied without specific information and/or documentation about the circumstances which led to the request.
4. Send the Request for Member Reassignment form to Provider Services.
   Facilitation of member reassignment request is the responsibility of the Provider Services department at the Alliance. Please send the Request for Member Reassignment form along with copies of the letter(s) to members to:Provider Services Department
   Central California Alliance for Health
   1600 Green Hills Road, Suite 101
   Scotts Valley, CA 95066Or fax to Provider Services at (831) 430-5857
5. How does the Alliance process the request?
   Processing of your request involves the following steps:
   • Review of Request for Member Reassignment form for completeness, accuracy, and appropriate details
   • Document member’s version of the events
   • Medical Director review and decisions to approve, defer or deny request
   • Verbal or written notification to requesting provider
   • Notification of member
6. What to do while you wait for the outcome of the request?
   The member will remain linked to your practice until the Alliance approves the request. If the request is approved, the member remains linked until the effective date identified in the letter notifying you often approval. The member will remain linked to your practice until the effective date indicated verbally or in writing from the Alliance. Until that date, you are required to ensure access to care by providing it yourself or referring the member out to another provider. Ensuring access to care includes prescribing or writing refills for any medically necessary notifications for the member. In additional, you are responsible for authorizing any specialty care services that the member may require until the effective date of reassignment.
7. If approved, when is the request effective?
   If your request is approved, typically the effective date of the reassignment is the first day of the month following the date your request is approved and processed by the Alliance. However, the Alliance may determine a later effective date to allow adequate time for internal processing and for contacting the member so that he/she may select another primary care provider.

Important note: The Alliance is accountable to state and federal regulatory agencies to ensure that physicians do not terminate care to patients inappropriately. Alliance members have the right to file a complaint if they perceive they were treated unfairly.

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