Transition of Care/Continuity of Care

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Continuity of Care Background

Transition of Care gives new members the option to request extended coverage from their current health care professional who will be out-of-network with the new plan. This is for a limited time due to a specific medical condition and may continue until the safe transfer to a network health care professional can be arranged. The provider must agree to accept network rates.

Continuity of Care gives existing members the option to request to extend care from their current health care professionals if they are or are soon to be out-of-network. Providers must notify members of the upcoming change in status prior to the effective date of such change and assist in the orderly transfer of members to another participating provider. Members with medical reasons preventing an immediate transfer to a network health care professional may request extended coverage for services at network rates for specific medical conditions for a defined period.

How Transition of Care/Continuity of Care Works

A member is eligible for a Transition of Care/Continuity of Care only when a member has a significant medical condition that requires continual care with a specific provider as determined in each individual situation. If a member’s request is approved for the medical condition(s) listed in the application(s), the member will receive the in-network level of coverage for treatment of the specific condition(s) by the health care professional for a defined period, as determined by BHN. All other services or supplies must be provided by a participating network health care professional for the member to receive in-network coverage levels. If a member’s plan includes out-of-network coverage and a member chooses to continue receiving care from the nonparticipating provider beyond the timeframe approved by BHN and agreed to by the provider, the member must follow the specific plan’s out-of-network requirements. Depending on the actual request, a medical necessity determination and a notification or prior authorization may still be required in order for service coverage.

Transition of Care/Continuity of Care Examples That Qualify

  • Pregnancy in the second or third trimester through six (6) weeks post-delivery
    • Transition of Care for the mother does not apply to the newborn. If the care provider or facility is out-of-network for the newborn, a Transition of Care request must be submitted for the newborn also.
  • Ongoing treatment for a life threatening condition.
  • Newly diagnosed or relapsed cancer and currently receiving chemotherapy, radiation therapy or reconstruction.
  • Ongoing treatment after a completed complex surgery or in the middle of a staged surgery.
  • Treatment for end-stage kidney disease and on dialysis.
  • Ongoing care after a recent organ transplant or on the waiting list for a transplant with a specific physician.
  • Ongoing treatment for acute significant psychiatric problems or other significant behavioral health services.
  • Ongoing treatment for a rare and complex medical condition requiring continuity with a specific specialist.

Transition of Care/Continuity of Care Examples That Do Not Qualify

  • Routine exams and pediatric care.
  • Care of chronic conditions like diabetes, arthritis, allergies, asthma, kidney disease and hypertension.
  • Elective surgeries and procedures.

Transition of Care/Continuity of Care Timeframe and Application

A member must apply for transition of care no later than thirty (30) days after the date coverage begins.

Please complete this application.