If you, or an eligible covered family member, are receiving care for a serious or chronic condition and your network providers are changing, you may be eligible to continue with your current care provider at the network benefit level for a period of time, even if that provider is not part of your new network. If you are enrolling in the Value or Value Plus option you may be eligible for this service if you change your network and/or claims administrator or if your care provider drops out of your current network. This is referred to as Transition of Care or Continuing Care services.
You must apply for Transition of Care services within 45 days following the October benefits enrollment deadline of October 31, 2011 (i.e., by December 15). See Example 1 below.
Example 1 – Annual Enrollment: If you have a chronic condition and you are receiving an active course of treatment, you may still be able to receive care with your current doctor for a limited period of time, generally 90 days, even though he or she is not in the benefit plan option you have chosen for the next plan year. To ensure your services are not disrupted, apply for Transition of Care services as soon as possible.
Example 2 – Provider Leaving Network: You have a chronic condition and you are receiving an active course of treatment. However, your doctor is dropping out of your current network but you are continuing your coverage with that network administrator. You may still be able to receive care with your current doctor for a limited period of time, generally 90 days, even though he or she is no longer in your network. To ensure your services are not disrupted, apply for Transition of Care services as soon as possible.
For more information about the process, see frequently asked questions about Preauthorization / Transition of Care / Clinical Policies. To apply, complete the Universal Transition of Care Services form and send to your network and/or claims administrator. The administrator will notify you if you are approved for Transition of Care services. Coverage generally lasts for 90 days.
Clinical Policies There may be some differences among the network and/or claims administrators regarding medical necessity and other clinical determinations. If you are changing administrators, talk to your provider to see if your current treatment plan is impacted or not. To research these differences, review each administrator’s clinical policies, which are available on their public websites.