National Clinical Services (NCS) 600 Transition/Continuity of Care Coverage California HMO Plan
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Defines the plan's requirements and procedures for providing continuity of care and completion of covered services for certain medical, mental health, and substance use conditions when providers terminate or are nonparticipating, applicable to fully insured commercial HMO products in California.
No material clinical or coverage changes in this revision.
Transition and Continuity of Care Coverage Criteria
Transition/Continuity of Care Coverage Criteria
The plan will provide completion of covered services for enrollees who were receiving care from a terminated or nonparticipating provider for the conditions listed below, subject to the limitations and exclusions described.
Eligible conditions
- Acute condition: completion of covered services provided for the duration of the acute condition.
- Serious chronic condition: completion of covered services provided for the time necessary to complete the course of treatment and arrange a safe transfer, as determined by the plan in consultation with the enrollee and provider; coverage shall not exceed 12 months from the provider's contract termination date or 12 months from the effective date for a newly covered enrollee.
- Pregnancy: the three trimesters and the immediate postpartum period; maternal mental health condition arising during pregnancy/peri/postpartum or up to one year after delivery — completion of covered services for maternal mental health shall not exceed 12 months from diagnosis or from the end of pregnancy, whichever occurs later.
- Terminal illness: completion of covered services provided for the duration of the terminal illness (incurable or irreversible condition with high probability of death within one year).
- Care of a newborn from birth to age 36 months: completion of covered services not to exceed 12 months from contract termination date or 12 months from the effective date for a newly covered enrollee.
- Performance of an authorized surgery or procedure that is part of a documented course of treatment: to be covered, the surgery or procedure must take place within 180 days of the contract termination date or within 180 days of the effective date of coverage for a newly covered enrollee.
Exclusions and contractual limitations
- No continuation of services for providers terminated for medical disciplinary causes, fraud or other criminal activity.
- Services or benefits not otherwise covered under the terms and conditions of the plan contract are not eligible for continuation.
- If the terminated or nonparticipating provider does not agree to comply with contractual terms (including payment rates), the plan is not required to continue the provider's services beyond the contract termination date.
Payment and administrative terms
- Completion of services will be provided consistent with payment rates and methods as described; member cost‑sharing remains as applicable under the plan.
Process and timing
- Member or provider must submit a Transition/TOC request form within 90 days of enrollment, re‑enrollment, provider leaving or network status change, or date on the notification letter, except for extenuating circumstances.
- Plan decision timeframe: within two business days after receipt of all necessary information (same business day for urgent/emergent requests).
Provider group and enrollee notices
- Provider group/hospital termination procedures include member notice timelines and regulatory filings as required (e.g., enrollee notices mailed 60 days prior, DMHC notifications).
TOC/COC approval criteria
TOC/COC may be approved when the request meets the eligibility and documentation requirements listed below; approval is subject to plan benefit terms and time limits.
Active course of treatment – qualifying situations
- Pregnancy (three trimesters and immediate postpartum).
- Maternal mental health condition: up to 12 months from diagnosis or end of pregnancy, whichever is later.
- Acute conditions: completion provided for duration of the acute condition.
- Authorized surgery/procedure documented to occur within 180 days of provider contract termination or within 180 days of effective date for a newly covered enrollee.
- Terminal illness: services for duration of the illness.
- Ongoing or disabling medical condition or serious/chronic mental illness: coverage to arrange safe transfer, not to exceed 12 months from termination or effective date.
- Chemotherapy, radiation, or other active oncology treatment initiated in the last 90 days.
- Care for a child ages 0–36 months: may be covered up to 12 months from contract termination or effective date.
- Organ or bone marrow transplant procedures.
Time limits and submission window
- TOC/COC Request form must be submitted within 90 days of enrollment/re‑enrollment, provider leaving/network status change, or date on the notification letter (exceptions for extenuating circumstances).
Narrow or sponsor‑specific networks
- Approval may permit care at the highest benefit level for a limited period; after the approved period, benefits may be reduced or unavailable according to the plan's network rules.
Form and provider requirements
- A separate TOC/COC form is required for each provider; the form must include patient, subscriber, group and provider information, signatures and supporting clinical documentation; oncology section requests recent treatment status, drug name, diagnosis, expected length and next visit dates, and diagnostic/CPT/HCPCS codes.
Continuity/Transition request criteria
Providers must complete the applicable sections of the Transition/TOC request form, attest to active course of treatment where indicated, and attach supporting clinical documentation.
Coding, Timeframes, and Diagnostic Indicators
| Fax (medical requests) | 1-859-455-8650 |
| Email (medical requests) | VFAXPrecert@aetna.com |
| Fax (mental health/substance abuse) | 1-888-463-1309 |
| DX | ICD-10 diagnostic code — enter primary and any secondary as applicable |
| CPT/HCPCS | Procedure or drug administration codes related to oncology treatment — e.g., infusion CPT codes, radiation therapy CPT codes, chemotherapy administration codes, drug J-codes or Q-codes as applicable |
| DX | ICD-10 diagnostic code — required in each request section (enter primary DX and additional as needed). |
| CPT | CPT procedure codes relevant to service (e.g., surgical follow-up visits, OB visits, IV therapy infusion codes, chemotherapy administration codes, radiation therapy codes). |
| HCPCS | HCPCS/CPT level II codes for supplies, drugs (J-codes/Q-codes), or home infusion supplies as applicable. |
Provider Submission, Notifications, and Obligations
Decision and Notification Timelines
Decisions regarding Transition Coverage Requests are made within two (2) business days of obtaining all necessary information, which includes a completed Transition of Care (TOC)/Continuity of Care (COC) Request form with all required fields filled. For urgent or emergent requests (acute conditions), decisions are made the same business day they are received. The plan will notify the provider telephonically within 24 hours of the decision and will notify the enrollee and the terminated or nonparticipating provider in writing within two (2) business days of the decision. If services were received prior to approval, those services must be approved by the Medical Director for coverage to be extended at the new plan level; the Medical Director will consider any Plan delays that affected receipt of services prior to approval.
Provider completion and submission requirements for transition/continuity of care requests
Providers must complete and submit a TOC/COC Request form (one form per provider) and include diagnostic and treatment information describing the active course of treatment. The provider section must be signed and dated and must: confirm whether the member is in an active course of treatment for specified categories (oncology, intravenous therapy, surgical follow-up/post-op, obstetrical/pregnancy, terminal illness, or other active courses of treatment); provide treatment start and expected end dates where applicable; list relevant diagnoses and CPT/HCPCS procedure codes; and attach all supporting clinical documentation. For pregnancies, include the estimated date of confinement (EDC). By submitting the form, the provider agrees to provide the patient’s treatment and follow-up, share treatment information with the plan, not seek payment beyond the member's contractual responsibility, and to use the plan’s network for referrals, labs, or hospitalizations for services not part of the requested treatment.
- Submit one completed TOC/COC Request form per provider.
- Complete Section 4 (provider information) including signature and date.
- Include diagnostic and treatment details, CPT/HCPCS and diagnosis codes, and visit dates.
- Indicate active course of treatment status for: oncology, IV therapy/TPN, surgical follow-up (within 90 days or series of procedures), obstetrical care (include EDC), and other active treatments.
- Attach all relevant clinical documentation to support the request.
- Fax medical requests to 1-859-455-8650 or email VFAXPrecert@aetna.com; fax mental health/substance abuse requests to 1-888-463-1309.
- Submit requests within applicable timelines (e.g., within 90 days of enrollment or network change) as required by the plan.
Scope, Definitions, and Covered Provider Types
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