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Provider Responsibilities

Termination of Health Services by a Provider

If a participating provider wishes to terminate health services to a member, the provider must notify Medica of his or her intention to discontinue health services to the member. Medica will verify with the provider that attempts were made to resolve the problem and will assist the member by providing the name, address and telephone numbers of other network providers in the same area of medical specialty and geographic location.

A provider may not terminate a member from their entire organization if a suitable provider (primary care, mental health or general hospital provider) does not exist within a 30-mile radius of a member’s residence, or for a specialist provider, within 60 miles of a member's residence.  If a provider following Medica's policy does terminate health services to a member, that termination may not extend to other Medica members in that household.


Circumstance for Termination of Health Services

The following circumstances may warrant refusal to provide health care services:

  • Unpaid copayments or coinsurance.
  • Outstanding/unpaid bills.
  • Uncooperative or abusive behavior toward a provider or provider’s staff.
  • Inability of the member and provider to agree on a course of treatment.
  • Consistently misses scheduled appointments.

In making such decisions, all parties will comply with applicable provisions of the Medica Participation Agreement and Medica’s agreements with the Centers for Medicare & Medicaid Services (CMS) and the Department of Human Services. In addition, all parties will cooperate to ensure continuity of care including, but not limited to, providing care until transitional care is located.

Before a participating provider can refuse to furnish health care services to a member, the member must be informed in writing of the nature of the problem and be given a minimum of 30 days to resolve it. The written communication to the member must also inform the member that the provider will refuse to furnish future services if the problem is not resolved.


Notification Requirements

To notify Medica of a potential termination of health services by a provider, please complete the Termination of Health Services Form.

Termination of Health Services form (DOC)

Please fax this form to:

Provider Relations Department
Fax: (952) 992-3270

Date: 6/4/2020 2:55:03 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01