Policy Statement: Dismissing Health First Colorado Members From a Provider’s Practice

A good relationship/partnership between health care provider and patient is essential for optimal treatment outcomes. If, for whatever reason, it is not possible to establish this partnership, it may be best for the patient to seek treatment elsewhere. The Department of Health Care Policy and Financing (the Department) has established the following policy regarding termination of a Health First Colorado (Colorado's Medicaid Program) provider/patient relationship. Termination of the provider/patient relationship should be evaluated on a case-by-case basis.

Fee-for-Service Health First Colorado

Providers may dismiss a Health First Colorado Member from their practice for cause at any time.  “Cause” is defined as any of the following:

  • A documented, ongoing pattern of failure on the part of the Member to keep scheduled appointments or meet any other Member responsibilities.
  • The Member fails to follow the recommended treatment plan or medical instructions.
  • The provider cannot provide the level of care necessary to meet the Member’s needs.
  • The provider moves out of the service area.
  • The Member and/or Member’s family is abusive to the provider and/or practice staff, or poses a serious threat of harm to the provider, staff, and/or other patients.
  • Other reasons satisfactory to the Department.

The provider shall give no less than a 45-day written notice of termination to both the Department and the Member. Written notice must include:

  • An agreement by the provider to continue provisional coverage of the Member’s health care needs for up to 45 days, while the Member obtains a new provider.
  • If possible, referral information to the Member regarding possible new providers.
  • Notification that the Member’s medical records will be sent to the new provider upon receipt of written authorization from the Member.

Written notice should be sent via the US Postal Service to the address below, or via fax to (303) 866-2803, Attention: Provider Relations.

Colorado Department of Health Care Policy and Financing
Attn:  Provider Relations Division
1570 Grant Street, Denver, CO 80203

Providers may not dismiss a Health First Colorado Member based on the Member’s gender[1], race, religion, or sexual orientation. Further, a provider relationship with a Member covered under the Americans with Disabilities Act (ADA) may be terminated only for reasons similar to those applied to a non-disabled Member. Relationships may not be terminated because of the Member’s disability or illness, or costs that the disability or illness might involve (e.g., providing an interpreter for a deaf Member).
 


[1] Unless the provider’s specialty is gender-specific.

Source: HCPF April 2015 Provider Bulletin and Colorado Medical Board Policy Number: 40-02 (revised 7/1/10)