National Clinical Services (NCS) 600 Transition/Continuity of Care Coverage California HMO Plan

Coverage Summary

Scope: This policy defines Aetna California HMO requirements and procedures for temporary Transition/Continuity of Care (TOC/COC) when a provider's network participation changes or when a member newly enrolls while receiving ongoing treatment. It applies to all fully insured commercial HMO products when the controlling state is California and to the listed departments/programs (for example: 24-Hour Nurse Line, Care Management, Disease Management, Behavioral Health, Precertification areas) as indicated in the policy scope.

Coverage stance: Covered with criteria. The plan will provide completion of covered services when the enrollee meets the situational criteria (terminated provider or nonparticipating provider) and the condition type and timing limits described in Section B of the policy.

Who/what this applies to: Members of Aetna California fully insured commercial HMO products, and providers (individual practitioners, provider groups, hospitals, and other licensed facilities) involved in ongoing courses of treatment where network status changes or when a member newly enrolls while receiving care.

Key thresholds summary: Surgery or other authorized procedures must be scheduled within 180 days of the provider contract termination date or within 180 days of the effective date for a newly covered enrollee. For certain condition categories (serious chronic conditions, newborn care to 36 months, maternal mental health) continuation periods shall not exceed 12 months from the provider contract termination date or from the effective date for a newly covered enrollee (maternal mental health: 12 months from diagnosis or from end of pregnancy, whichever is later). Standard decisions are made within 2 business days of obtaining all necessary information and urgent decisions for acute conditions are made the same business day they are received.

Key Thresholds / Timeframes

Surgery/procedure timingWithin 180 days of the provider's contract termination date or within 180 days of the effective date of coverage for a newly covered enrollee

Serious chronic / newborn / maternal mental health max durationNot to exceed 12 months from provider contract termination date or 12 months from effective date for newly covered enrollee; maternal mental health: 12 months from diagnosis or from end of pregnancy, whichever is later

Decision timeline (standard)Decisions made within 2 business days of obtaining all necessary information

Decision timeline (urgent/emergent)Decisions for urgent/emergent requests regarding acute conditions made the same business day they are received

Form submission timeframeSubmit Transition Coverage Request Form within 90 days of enrollment/re-enrollment or within 90 days from date of provider contract discontinuation or network status change (exceptions allowed for extenuating circumstances)

Situations and Operational Criteria for Transition/Continuity of Care

Provider Requirements and Actionable Items

Prior Authorization

Submit Transition/Continuity of Care Request Form

Providers (or members) must complete and submit a separate Transition Coverage Request Form for each provider to request continuation of services. The form must include diagnostic and CPT/HCPCS codes and attach supporting clinical documentation.

Documentation Required

Provider agreement and documentation requirements

Nonparticipating or terminated providers may be required to agree in writing to the plan's contractual terms and to provide clinical documentation of an active course of treatment. The plan may deny continuation if the provider does not agree or comply with credentialing, privileging, utilization review, peer review, quality assurance, or other contractual requirements.

Coding and Form Fields

Form / Diagnostic CPT/HCPCS fields (examples in form)mixed

CPT/HCPCS (form placeholder)

The Transition Coverage Request Form includes fields to list diagnostic and CPT/HCPCS codes relevant to the request (no specific codes mandated in this part).

Background and Definitions

Background / Rationale: This amendment was written to meet regulatory and statutory requirements under the California Health & Safety Code (including sections 1373.96 and 1373.95), DMHC Rule 1300.67.1.3, and DMHC Administrative Policy Letter APL 19-013 that affect Transition/Continuity of Care policy and procedure.

Applicability: These requirements apply when the controlling state is California and expressly apply to fully insured commercial HMO products. The policy is scoped to specific departments and programs listed in the policy (for example 24‑Hour Nurse Line, Care Management, Disease Management, Behavioral Health, Precertification activities and related programs) as shown on the policy scope.

Definitions:

• Individual provider: A person who is a licentiate as defined in Section 805 of the Business and Professions Code or a person licensed under Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code (CA Health & Safety Code 1373.96(n)(1)).

• Nonparticipating provider: A provider who is not contracted with a health care service plan (CA Health & Safety Code 1373.96(n)(3)).

• Nonparticipating mental health provider: A psychiatrist, licensed psychologist, licensed marriage and family therapist, licensed professional clinical counselor, or licensed social worker who does not contract with the specialized plan offering professional mental health services on an employer-sponsored group basis (CA Health & Safety Code 1373.95(e)(2)).

• Provider group: A medical group, independent practice association (IPA), or any other similar organization (CA Health & Safety Code 1373.96(n)(5)).

• Pharmaceutical items: Medications that are used to diagnose, cure, treat, or prevent disease (plan definition).

Frequently Asked Questions

Q: What is an active course of treatment?

A: An active course of treatment means you have been receiving services from your doctor to correct or treat a diagnosed condition. The start date is the first date of service or treatment. An active course of treatment covers a defined number of services or period of treatment and includes qualifying situations such as pregnancy, chemotherapy, radiation, terminal illness, or care for children 0–36 months; completion periods for certain conditions (e.g., serious chronic conditions, newborn care, maternal mental health) are capped at 12 months as described in the policy.

Q: How do I sign up for TOC/COC coverage?

A: Contact the Member Services number on your member ID card and submit a TOC/COC Request form to the health plan: within 90 days of enrollment/re-enrollment, within 90 days of the date the provider left the plan's network or the date on the notification letter, or within 90 days of a provider's network status change. You or your provider can call or send in the request form.

Q: Will I have to pay more if I continue with an out-of-network provider?

A: No. If TOC/COC is approved, enrollee cost-sharing (co‑payments, deductibles, and other cost-sharing components) during continuation with the provider shall be the same as if receiving care from a participating provider.

Revision History

2025-11-18Last review

Last Review Date as listed on the Document Information / Review and Revision History

2025-11-18Next reviewLatest

Next Review Date as listed on the Document Information / Review and Revision History

2025-11-18Effective date (Document Information Page)

Effective Date shown on the Document Information Page