Library: Policy

317:25-7-27. Changing Primary care providers (PCPs)

Revised 9-14-20

(a) The Oklahoma Health Care Authority (OHCA) is responsible for changing a member's enrollment from one (1) PCP to another:

(1) Without cause upon the member's request; or

(2) Upon demonstration of good cause.For purposes of this paragraph, good cause means:

(A) Those members who are habitually non-compliant with the documented medical directions of the provider; or

(B) Those members who pose a threat to employees, or other patients of the PCP; or

(C) As a result of a grievance determination by the OHCA; or

(D) In those cases where reliable documentation demonstrates that the physician-patient relationship has so deteriorated that continued service would be detrimental to the member, the provider or both; or

(E) The member's illness or condition would be better treated by another type of provider; or

(3) when the state imposes an intermediate sanction.

(b) A written request by the PCP to change the enrollment of a member is acted upon by the OHCA within thirty (30) days of its receipt. The decision to change PCPs for cause is made at the discretion of the OHCA, subject to appeals policies delineated at Oklahoma Administrative Code 317:2-1.The effective date of change is set so as to avoid the issue of abandonment.

(c) In the event a SoonerCare PCP contract is terminated by OHCA for any reason, or the PCP terminates participation in the SoonerCare Choice program the panel members formerly aligned with the terminating PCP shall be enrolled with a different PCP.