CurrentAdvanced HealthPolicy N/A

Transition of Care Policy and Procedures

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This policy governs how Advanced Health ensures uninterrupted access to covered medical services, prescriptions, care coordination, transportation, and previously authorized services when Medicaid Members transition from a predecessor CCO or Medicaid fee-for-service. It applies to eligible Members and assigns operational responsibilities for identification, authorization, data exchange, claims, care coordination, and monitoring.

Policy Summary

PayerAdvanced Health

PolicyTransition of Care Policy and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewDec 29, 2025

Next Review DateN/A

Key ActionEnsure eligible Members have continued access to care and Non-Emergency Medical Transportation during the transition period, including access through the Member's previous provider even when that provider is outside the Advanced Health network.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysDual-eligible transition period

30/60 daysPhysical/behavioral health transition periods

7 daysHistorical data response deadline

24 months

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CurrentAdvanced HealthPolicy N/A

Transition of Care Policy and Procedures

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Policy Summary

PayerAdvanced Health

PolicyTransition of Care Policy and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewDec 29, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysDual-eligible transition period

30/60 daysPhysical/behavioral health transition periods

7 daysHistorical data response deadline

24 months

Prior authorization history

5 yearsElectronic payer data exchange

Medicaid FFSNonparticipating provider reimbursement floor

Transition of Care Requirements

Members requiring continued access

Advanced Health must provide continued access to care at a minimum for Members meeting ANY of the following criteria:

ANY of

Medically Fragile Children
Breast and Cervical Cancer Treatment program Members
Members receiving CareAssist assistance due to HIV/AIDS
Members receiving services for end stage renal disease, prenatal or postpartum care, transplant services, radiation, or chemotherapy services
Members who, without continued access to services, may suffer serious detriment to their health or be at risk of hospitalization or institutionalization

Transition continuity requirements

During the transition of care period, covered services and ongoing treatment must be continued when ALL of the following requirements apply:

ALL of the following

Provide continued access without delay to medically necessary covered services, prescriptions, prescription drug coverage, and Non-Emergency Medical Transportation (NEMT)
Permit the Member to continue receiving services from the previous provider, regardless of whether that provider participates in Advanced Health's network; refer the Member to appropriate in-network providers after the transition of care period
Continue the entire applicable course of treatment with the previous provider, including prenatal and postpartum care, transplant services through the first year post-transplant, the current course of radiation or chemotherapy, or prescriptions with a defined minimum course of treatment that exceeds the transition of care period
Honor written documentation of prior authorization for ongoing covered services and do not delay service authorization when written authorization documentation or historical clinical records are not available in a timely manner

Receiving and predecessor CCO obligations

Transition responsibilities depend on whether Advanced Health is the receiving or predecessor CCO. Meet the applicable obligation below:

ONE of

As the receiving CCO, do not delay the provision of services when historical utilization data and clinical records are not available in a timely manner; approve affected claims during the transition of care period as if the covered services were prior authorized
Applies when Advanced Health receives the Member.
As the predecessor CCO, provide complete historical utilization data to the receiving CCO within 7 calendar days of the request through a secure method of file transferWithin 7 calendar days of the request
Applies when Advanced Health is the predecessor CCO.

Transition Parameters and Data Requirements

Required clinical diagnosis dataICD-10

ICD-10

Current ICD-10 diagnoses must be included in historical utilization data transferred by a predecessor CCO.

Dual-eligible transition period

Transition duration90 days after the effective date of enrollment with the receiving CCO

PopulationMembers dually eligible for Medicaid and Medicare

Transition startThe effective date of enrollment with the receiving CCO

Physical and oral health transition period

Physical and oral health limit30 days

Earlier milestoneThe new applicable provider reviews the Member’s treatment plan

Treatment-course milestone

Operational Actions During Transition

Documentation Required

Maintain continuity with prior providers

Ensure eligible Members have continued access to care and Non-Emergency Medical Transportation during the transition of care period. Members may continue receiving services from their previous provider, regardless of whether that provider participates in the Advanced Health network.

Documentation Required

Continue specified treatment courses

Continue the entire course of treatment with the Member’s previous provider for prenatal and postpartum care, transplant services through the first year post-transplant, and the current course of radiation or chemotherapy. Continue prescriptions with a defined minimum course of treatment that exceeds the transition of care period.

Prior Authorization

Key Transition Definitions

Continued Access to Care

Covered servicesMedically necessary covered services provided without delay

Medication accessPrescriptions and prescription drug coverage provided without delay

Provider continuityThe Member may retain the current provider, even if that provider is not in the CCO network

Medically Fragile Children

PopulationChildren with a health impairment

Required needsLong-term, intensive, specialized services on a daily basis

Eligibility

Policy Summary

PayerAdvanced Health

PolicyTransition of Care Policy and Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Last ReviewDec 29, 2025

Next Review DateN/A

SourceLink

On This Page

When required historical data, clinical records, or written authorization documentation is unavailable, approve affected claims during the transition of care period as if the covered services were prior authorized

The minimum or authorized prescribed course of treatment has been completed

Behavioral health transition period

Behavioral health limit60 days

Earlier milestoneThe new applicable behavioral health provider reviews the Member’s treatment plan

Treatment-course milestoneThe minimum or authorized prescribed course of treatment has been completed

Historical data response deadline

Response deadlineWithin 7 calendar days of the request

Applicable roleWhen Advanced Health is the predecessor CCO

Transfer methodSecure method of file transfer

Prior authorization history period

Required historyPrior authorizations for services rendered during the preceding 24 months

Current authorizationsCurrent prior authorizations and pre-existing orders

Additional utilization dataCurrent behavioral health services, active prescriptions, and current ICD-10 diagnoses

Electronic payer data exchange period

Data receivedReceive data from any other payer that provided coverage to the Member within the preceding 5 years

Data sentSend data during current CCO enrollment and up to 5 years after disenrollment

Electronic formatSend data received from another payer in the electronic form and format in which it was received

Nonparticipating provider reimbursement floor

Minimum reimbursementNo less than Medicaid fee-for-service rates

Applicable providersNonparticipating providers used when the Member continues with a previous provider

Rule referenceConsistent with OAR 410-120-1295

Transplant continuation period

Continuation periodThrough the first year post-transplant

Service coveredTransplant services

Continuity requirementContinue the entire course of treatment with the recipient’s previous provider

Honor prior authorizations and missing records

Honor written documentation of prior authorization for ongoing covered services. Do not delay service authorization when written authorization documentation or historical clinical records are not available in a timely manner; approve affected claims during the transition period as if the covered services were prior authorized.

Denial Risk

Issue adverse authorization notices

Follow all applicable service authorization protocols and provide the Member written notice of any decision to deny a service authorization request, authorize less than the requested amount, duration, or scope, or reduce a previously authorized service authorization.

Documentation Required

Obtain transition documentation

Obtain written documentation as necessary for continued access to care from the Authority’s clinical services for Members transferring from fee-for-service, from other CCOs, and from previous providers when Member consent is necessary.

Documentation Required

Identify and route transition cases

Use automated processes whenever possible to identify Members eligible for transition-of-care services. Direct manual requests to Customer Service, forward relevant information to Utilization Review for eligibility review, and enter or update requests in Quantum Choice with a TOC notation.

Documentation Required

Record transition authorizations

Enter complete and accurate transition authorization details in the Quantum Choice system, then pend the authorization to the designated transition-of-care queue for processing and review.

Include the authorization date range.
Include service quantities.
Include the provider and service type information.

Prior Authorization

Proceed when incoming records are delayed

When Advanced Health is the receiving CCO and historical utilization data or clinical records are not available in a timely manner, do not delay the provision of services. Approve affected claims during the transition of care period as if the covered services were prior authorized.

Found eligible for medically fragile children services by the Department of Human Services, as defined by OAR 411-300-0110

Transition of Care Period

DefinitionThe period after the effective date of enrollment with the receiving CCO

Responsible organizationThe receiving CCO

Required actionProvide continued access to services during the period

Covered transition population

Included MembersMembers immediately after disenrollment from a predecessor plan or Medicaid fee-for-service

Termination-related disenrollmentIncludes disenrollment caused by termination of the predecessor CCO’s contract

ExclusionMembers with a gap in coverage after disenrollment from the predecessor plan