A payer does not need a reason to end a contract. A without-cause termination only needs the notice the agreement requires, plus whatever longer period a state or federal rule sets above it. The billing consequences do not wait: on the effective date the practice becomes out of network, the contracted rates stop applying to new dates of service, and the patients who were mid-treatment become the first problem to solve. This is what the notice has to contain, what you owe your patients, and how to run the quarter that follows.
What this covers
- A without-cause termination runs on a notice clock, and 42 CFR 422.202(d)(4) sets a 60-day federal floor for Medicare Advantage on both sides.
- State law often sits above the contract. New Jersey and Texas require 90 days written notice to the provider; Florida and Washington require 60.
- A Medicare Advantage plan must also tell its CMS Account Manager 90 days ahead of a significant no-cause termination, and tell enrollees 45 days ahead when the provider is primary care or behavioral health.
- The No Surprises Act gives a continuing care patient up to 90 days of continued in-network coverage, and the practice has to accept the plan’s payment as payment in full for that care.
- Claims for services rendered before the effective date still pay at contracted rates. What changes is every date of service after it.
The notice period is the practice’s planning window. Everything that has to happen before the effective date, from patient calls to a replacement contract, has to happen inside it.the calendar, not the letter, is the real deadline
A network contract ends three ways: it expires, one side declines to renew it, or one side terminates it early. An early termination for cause usually follows a quality or integrity problem and can take effect at once. A termination without cause is the one a practice can plan around, because it runs on a clock that the contract and the law together set.
Who can end the contract, and on what notice
The contract sets the first number. The federal floor for Medicare Advantage sits at 42 CFR 422.202(d)(4): the plan and the contracting provider must each give the other at least 60 days written notice before terminating without cause. Commercial and Medicaid managed care agreements commonly set 90 days or more, and a few states put their own floor above the contract.
| Source | Who must give notice | Minimum | What it covers |
|---|---|---|---|
| 42 CFR 422.202(d)(4) | MA plan and provider, each to the other | 60 days | Termination without cause in Medicare Advantage |
| Medicare Managed Care Manual 110.1.2.2 | MA plan to its CMS Account Manager | 90 days | Significant no-cause provider termination |
| New Jersey N.J.A.C. 11:24B-5.3(c) | Carrier to the provider | 90 days | Network termination, with narrow exceptions |
| Texas 28 TAC 11.901(d) and Ins. Code 843.306 | HMO to the physician or provider | 90 days | Termination, plus a written statement of reasons |
| Florida 641.315(2)(b) | HMO to the provider | 60 days | Cancellation without cause |
| Washington WAC 284-170-421(11) | Issuer and provider, each to the other | 60 days | Termination without cause |
The 90-day notice in the title is not one rule. It is the number that shows up in the Medicare managed care manual for a plan’s report to CMS, in the New Jersey and Texas statutes for the notice a payer owes a provider, and in the No Surprises Act for the continuity window. A practice that hears 90 days and stops listening will miss which clock is actually running.
Pull the exact clause. It names the notice period, who sends it, whether the period runs from the date sent or the date received, and whether the contract renews automatically. Those four facts decide your calendar.
What the payer’s notice has to contain
When a Medicare Advantage plan ends a provider contract, the enrollee notice is prescribed at 42 CFR 422.2267(e)(12). It must go out in hard copy by U.S. mail, and it must carry a fixed list of items.
- The date the provider leaves the network.
- Names and phone numbers of in-network providers the enrollee can use for continued care.
- An explanation of how the enrollee can ask to continue ongoing treatment or therapies with the departing provider.
- Information on the annual coordinated election period and Medicare open enrollment, and the option to call 1-800-MEDICARE to switch coverage or request a special election period.
- The plan’s call center number, TTY number, and hours of operation.
Timing is separate from content. Under 42 CFR 422.111(e), the plan must give written notice, and attempt one phone call, at least 45 calendar days before the effective date when the provider is a primary care or behavioral health provider. For every other specialty the written notice is due at least 30 calendar days before. The plan owes that notice whether the termination is for cause or without cause.
The provider-facing notice is different. Under 42 CFR 422.202(d)(1), a plan that suspends or terminates a physician’s agreement must state the reasons, including any standards or profiling data it used, and explain the physician’s right to appeal and how to request a hearing. Texas goes further: before terminating a contract, an HMO must give the physician or provider a written explanation of the reasons, and the provider can request a review by an advisory review panel.
A plan’s enrollee notice tells the patient what to do next. It does not tell the practice which claims are still covered, when the runout ends, or what rate applies to a continuing care patient. Those answers live in your contract and in the plan’s provider manual.
The patient notice clock and continuity of care
The No Surprises Act, at 42 U.S.C. 300gg-113, gives certain patients a right to keep seeing a provider at in-network terms after the provider leaves the network. The protection applies when a contract termination changes the provider’s network status, and it runs for up to 90 days.
The patient has to qualify as a continuing care patient. The statute lists five categories: a serious and complex condition, institutional or inpatient care, a scheduled nonelective surgery, pregnancy, or a terminal illness. A stable chronic condition managed by routine care usually does not meet the serious and complex test.
The mechanics matter to the practice. The plan must notify a continuing care patient of the termination and the right to elect continued care. The 90-day window starts when the plan sends that notice, and it ends earlier if the patient stops being a continuing care patient. During the window the practice must accept the plan’s payment, plus the patient’s cost sharing, as payment in full for that course of treatment.
Some states add their own continuity duty that outlasts the federal window. New Jersey requires a terminated physician to keep treating covered persons for up to four months where it is medically necessary, six weeks after delivery for a pregnancy, six months for post-operative care, and one year for oncology or psychiatric treatment.
- Identify continuing care patients before the effective date, not after the first denial.
- Confirm the plan sent the notice, and record the date it was sent. The 90-day clock runs from that date.
- Get the patient’s election to continue care in writing.
- Bill the prior contracted rate and hold the patient to in-network cost sharing for the transition period.
- Document medical necessity for each continued course of treatment.
- Set a reminder for the day the window closes, and plan the handoff before it does.
The revenue plan for the quarter after
The effective date splits the claims. Services rendered before it still pay at contracted rates, subject to the contract’s runout or tail provision and the payer’s timely filing rule. Services rendered after it are out of network unless a continuity right or a single-case agreement covers them. The quarter after the notice is a sequence of five moves.
Log the notice date, the effective date, and the notice period the contract requires. If the payer is short, raise that in writing.
List every active patient with an appointment or an authorization that crosses the effective date. Sort them into continuing care patients and everyone else.
For continuing care patients, confirm the plan’s notice and the patient’s election. For the rest, request a single-case agreement at the prior rate.
Rebuild expected collections for the quarter on out-of-network terms for post-termination dates, and flag the visits that cannot be re-priced.
Start enrollment with the plans that will cover these patients, and get the credentialing file moving before the effective date.
The behavioral health codes make this concrete. An authorization for 97153 often covers a set number of units across several weeks. If the contract ends mid-authorization, the plan may honor units already approved and deny the rest. The fix is a single-case agreement that names the code, the units, and the dates, agreed before the effective date.
A runout clause lets claims for services rendered before the termination date process at contracted rates for a set period. Check the length and the timely filing limit. A claim filed after the runout closes is a denial, even when the service was covered.
Where the money leaks after the effective date
The denials arrive in a pattern. Claims for post-termination dates come back as out-of-network or as no active contract, and the patient balance shifts to a rate the family never agreed to. The defense is a clean split by date of service and a denial log that sorts by reason rather than by volume.
- Date-of-service denials: post-termination claims priced out of network, or denied for no participating provider agreement.
- Continuity claims: post-termination services for a continuing care patient denied because the plan has no election on file.
- Authorization gaps: units approved under the old contract not honored after the effective date.
- Timely filing: runout claims that miss the payer’s filing window during the transition.
- Patient responsibility: balances moved to the patient before the practice has re-priced the service.
Each one is a worklist. A date-of-service sort separates the claims that should pay from the ones that need an appeal, and a continuity election on file turns a denial into a reprocessed claim. That is the same discipline denial management applies to any payer problem.
Billing a continuing care patient at out-of-network rates while the plan’s obligation is still open creates a refund problem and a complaint. Confirm the plan’s position before the statement goes out.
Read your own contract before the notice arrives
The best time to find the termination terms is before anyone uses them. Pull every payer agreement and record six clauses in one place.
- The termination for convenience clause: notice length, and whether it runs from send or receipt.
- The runout or tail provision: how long claims for pre-termination services still pay.
- The continuity-of-care clause: what the payer owes, and what the practice must accept.
- The renewal clause: automatic renewal dates and the window to give notice.
- The single-case agreement process: who approves one, and how fast.
- The dispute path: the appeal or advisory review the contract allows, and its deadline.
Two of these protect revenue directly. A runout provision keeps the last month of claims priced correctly. A continuity clause decides whether a mid-treatment patient stays at the prior rate. Both are worth negotiating at renewal, and both are cheap next to the collections they protect.
When the practice has to rebuild a network, the work is credentialing again, and the clock belongs to the payer. Enrollment effective dates and the payer’s revalidation cycle decide when the first clean claim pays. For practices that would rather not rebuild the whole cycle in-house, medical billing services can carry the transition while the contracts are sorted out.
Insurance contract termination questions
Yes, when the contract allows termination without cause. The payer owes the notice period the agreement requires, plus any longer period a state or federal rule sets. Medicare Advantage sets a 60-day floor for either side under 42 CFR 422.202(d)(4). New Jersey and Texas require 90 days written notice to the provider. A without-cause termination is a business decision, not a finding of fault.
For a primary care or behavioral health provider, the plan must give written notice and attempt one phone call at least 45 calendar days before the effective date, to enrollees assigned to that provider and to anyone treated by them in the past three years. For other specialties, written notice is due at least 30 calendar days before. The rule applies whether the termination is for cause or without cause.
A patient in one of five categories at the time the provider leaves the network: treatment for a serious and complex condition, institutional or inpatient care, a scheduled nonelective surgery, pregnancy, or a terminal illness. The patient can elect to keep the same benefits for up to 90 days from the date the plan notifies them of the network change, and the provider must accept the plan’s payment as payment in full.
Only when a right or an agreement covers it. A continuing care patient’s elected treatment pays at the prior contracted rate, with the patient held to in-network cost sharing. Otherwise the service is out of network and priced on those terms, or covered by a single-case agreement negotiated before the effective date. Services rendered before the effective date still pay at contracted rates under the runout clause.
For Medicare Advantage, 42 CFR 422.202(d)(1) requires written notice of the reasons for the action, including any standards or profiling data used, and an explanation of the provider’s right to appeal and how to request a hearing. Texas requires an HMO to give a written explanation of the reasons before terminating, and the provider may request review by an advisory review panel within 30 days.
It is the plan’s report to CMS, not a patient notice. Under the Medicare Managed Care Manual at section 110.1.2.2, a plan must notify its CMS Account Manager at least 90 days before a significant no-cause provider termination takes effect. CMS can then review the network for adequacy. It is separate from the 45-day and 30-day enrollee notices and from the 90-day continuity window.
The bottom line
A network termination is a contract event with a fixed calendar. The practice that reads its notice clause, protects its continuing care patients, and re-prices the quarter before the effective date keeps the revenue the contract was worth. The ones that react after the first denial spend the next quarter collecting it back.
Is a payer ending your contract this year?
Send the termination notice and one month of claims. The MedFactor team will map the effective date against your runout, continuity and authorization terms, then show which claims are at risk and what the transition is worth.
Request a free contract termination reviewThis article describes general contract termination, Medicare Advantage and continuity-of-care rules rather than legal advice, and notice periods, continuity rights and filing limits are set by each contract and each state, so confirm them against the agreement and the policy in effect on the date of service.
