Dismissal and Disenrollment Guidelines

Although there are Oregon Health Authority (OHA) guidelines for disenrollment of Members, Yamhill CCO is responsible for establishing policies and procedures for dismissal of a Member from a clinic or medical practice. The philosophy of Yamhill CCO is to encourage Members and the assigned Provider to resolve complaints, problems, and concerns at the clinic level whenever possible. The Provider should document the attempts taken to resolve the issue, address barriers and assistance provided to the Member. Before discharging or dismissing a Member or requesting a Member be disenrolled from Yamhill CCO, the PCP must request Yamhill CCO involvement to help resolve the problem or concern.

If the decision is reached to dismiss a Member, a letter must be sent to the Member informing the Member of the dismissal. The letter must include the reason for the dismissal and any actions taken to resolve the issue. The letter must also include the Member’s name, date of birth, address, and client number. Secure email a copy of the discharge letter to Providerrelations@Yamhillcco.org

Upon receipt of the request, Yamhill CCO will render a decision within five (5) business days on whether the request has been approved. Provider Relations will be notified of any potential reassignment request. The Contracting Department will contact the Provider for remediation strategies. If this issue involves missed appointments, a reminder that Yamhill CCO Members cannot be billed for missed appointments.

PCPs are asked to provide urgent care for the dismissed Member for 30 days after the Member is notified of the dismissal to ensure continuity of care.

Requirements

OHA has established specific requirements for when a Member can be disenrolled from the Member’s designated CCO. These requirements are outlined in detail in Yamhill CCO Policy ENR-005.

Request for disenrollment from Yamhill CCO may occur for the following reasons consistent with OAR 410-141-3810. These include:

• When a Member makes credible threats of or commits acts of violence.
• Evidence of uncooperative or disruptive behavior except where this is a result of the Member’s special needs or disability.
• Commits fraudulent or illegal acts.

Should you encounter any of these situations, contact Yamhill CCO Provider Relations for assistance.

When a Member Cannot be Dismissed

According to OHA Administrative Rule 410-141-3800-3810, Members cannot be dismissed from a PCP or disenrolled from Yamhill CCO solely because of any of the following reasons:

• The Member has a physical or mental disability.
• The Member has an adverse change in health.
• The PCP or Yamhill CCO believes the Member’s utilization of services is either excessive or lacking, or the Member’s use of plan resources is excessive.
• The Member requests a hearing.
• The Member exercises the option to make decisions regarding the Member’s medical care and the Provider/Yamhill CCO disagree with the Member’s decisions.

Definitions

Disenrollment: When a Member is removed from Yamhill CCO as the Member’s designated CCO following specific guidelines established by the Oregon Health Authority.

Dismissal: When a Member is removed from a clinic or medical practice following specific guidelines established by Yamhill CCO and in accordance with established OHA guidelines.

Verbal abuse: Abusive language that contains a menacing tone with the intent of threat and is often accompanied by physical and language clues.

For more information, please refer to the YCCO Provider Handbook, Section 5.11.