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Provider Group Block Transfer Filing Form


Download Provider Group Block Transfer Filing Form - MS Word

If a plan has an upcoming contract termination with a Provider Group, at least 75-days prior to the contract termination, a Block Transfer filing must be made with the Department. A "Provider Group" is defined by Rule 1300.67.1.3(a)(6).

If fewer than 2,000 enrollees are assigned to the Provider Group, a Block Transfer filing does not need to be made with the Department. An Enrollee Transfer Notice, that complies with Rule 1300.67.1.3(b)(1) would, however, need to be sent to Affected Enrollees at least 60-days prior to the contract termination. The notice must be approved by the Department.

Plans must complete the Provider Group Block Transfer Filing Form and then email the form to the following address: termination@dmhc.ca.gov. The form must be completed in its entirety, with all necessary attachments provided.


 
 
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