Aetna TOC/COC Coverage Update

Coverage Criteria — Transition / Continuity of Care

inv-01: Conditions eligible for completion of covered services

Covered when ANY of the following conditions apply to a member receiving treatment from a terminated or nonparticipating provider at the time of contract termination or coverage effective date:

Eligible conditions: 1) Acute condition: sudden onset requiring prompt medical attention; completion of covered services provided for the duration of the acute condition.

Eligible conditions: 2) Serious chronic condition: disease or disorder that is serious in nature, persists or worsens over time, or requires ongoing treatment; completion of covered services provided for period necessary to complete treatment and arrange safe transfer, not to exceed 12 months from contract termination.<= 12 months

Eligible conditions: 3) Pregnancy: the three trimesters of pregnancy and the immediate postpartum period; completion of covered services provided for the duration of the pregnancy.

Eligible conditions: 4) Maternal mental health condition: mental health condition impacting a woman during pregnancy, peri- or postpartum, or arising up to one year after delivery; completion of covered services shall not exceed 12 months from diagnosis or from the end of pregnancy, whichever occurs later.<= 12 months

Requires written documentation of diagnosis from treating health care provider.

Eligible conditions: 5) Terminal illness: incurable or irreversible condition with high probability of causing death within one year; completion of covered services provided for the duration of the terminal illness.

Eligible conditions: 6) Care of a newborn age 0–36 months: completion of covered services shall not exceed 12 months from the contract termination date.<= 12 months

Eligible conditions: 7) Surgery or other procedure authorized as part of a documented course of treatment and recommended to occur within 180 days of the contract termination date or within 180 days of the effective date of coverage for a newly covered enrollee; includes postoperative care.<= 180 days

Policy does not apply if enrollee is offered an out-of-network option.

inv-02: Contractual and provider participation requirements

Continuation of services is subject to ALL of the following requirements:

Contractual requirements: The continued provider may be required to agree in writing to the same contractual terms and conditions imposed prior to termination or those imposed on participating providers in the same or similar geographic area (e.g., credentialing, hospital privileging, utilization review, peer review, quality assurance).

If the provider does not agree to comply with these contractual terms or accept payment rates comparable to participating providers, the plan is not required to continue the provider's services.

Payment and billing: Services shall be compensated at rates and methods similar to those used for currently participating providers in the same or similar geographic area; the provider who agrees to provide services shall accept reimbursement as payment in full and shall not bill the plan for amounts in excess of the reimbursement rate (except member cost-sharing).

Plan or provider group is not required to continue services if provider refuses the payment rates.

Exclusions for certain terminations: Services need not be continued if the provider was terminated for medical disciplinary reasons, fraud, or other criminal activity, or if the services are not covered benefits under the plan contract.

inv-03: Request submission and decision process

Requirements to obtain transition coverage:

Submission—who and how: Member or treating provider must submit a completed Transition/Continuity of Care Coverage Request Form (one form per provider). The form must be completed by the insured and provider sections as applicable and faxed or emailed to the plan (fax and email addresses provided on the form).

Fax medical requests to 1-859-455-8650; email to VFAXPrecert@aetna.com; separate fax for mental health/substance abuse.

Submission—timing: Requests must be submitted within 90 days of enrollment or re‑enrollment, within 90 days of the date the provider left the plan's network or notice of the change, or within 90 days of a doctor's network status change.<= 90 days

You or your doctor can send in the request form.

Required information: A completed request form and the diagnostic/treatment information requested on the form are required; necessary information must be obtained before a decision is made and clinical documentation describing the active course of treatment should be included.

inv-04: Transition/Continuity of Care coverage criteria

Covered when ALL of the following are met

Member and timing eligibility: Member is a fully insured commercial Traditional (non‑HMO) member in California and a TOC/COC request form is submitted within 90 days of enrollment/re‑enrollment, provider leaving the network, or provider network status change.90 days

Form may be submitted by the member or the treating provider.

Active course of treatment: The treatment was initiated before the member's effective date with the plan or before the provider's contract termination or network‑status change (examples include pregnancy/OB care, oncology treatments, IV therapy, surgical follow‑up within 90 days post‑op, or other ongoing treatments).treatment already initiated

Clinical documentation required describing current condition, treatment start date, and expected course; form includes diagnostic and CPT/HCPCS code fields.

Provider commitments upon approval:

Transition/Continuity of Care coverage does not apply to durable medical equipment (DME) vendors or pharmaceutical items. If TOC/COC is approved, the treating provider must use a DME vendor or pharmacy vendor in the plan's network. If a provider or facility outside the plan network is requested, the member should contact Member Services as indicated on the member ID card.

Operationally, the plan is not required to continue services if the nonparticipating provider does not accept the payment rates or contractual terms outlined by the plan; providers who agree to provide services must accept the plan reimbursement as payment in full (except for member copayments and deductibles).

TOC/COC coverage does not apply to plans that do not have a provider network. Members or providers should confirm network-based eligibility before submitting a TOC/COC request; questions can be directed to the Member Services phone number on the member ID card.

Requested Diagnostic and Procedure Codes

Requested Diagnostic and CPT/HCPCS Codes (form placeholders)mixed

DX:	Diagnostic code placeholders as requested on the form
CPT/HCPCS:	Procedure code placeholders as requested on the form

Provider Submission, Documentation, and Operational Requirements

Documentation Required

Submission requirements and required documentation

A completed Transition/Continuity of Care Coverage Request Form (one form per treating provider) and all required clinical documentation must be submitted for review. The treating provider must complete Section 4 and include diagnostic and treatment information (diagnoses, CPT/HCPCS codes, dates of service, current treatment plan, and supporting clinical records). Be sure to complete all fields on page 5 before submission to avoid delays.

Fax medical requests to 1-859-455-8650; email requests to VFAXPrecert@aetna.com. Fax mental health/substance abuse requests to 1-888-463-1309.
Submit one form per provider; include all clinical documentation describing the active course of treatment and any relevant dates of service.
Necessary information includes a completed Transition of Care form and information required by the form (diagnostic and treatment details).

Prior Authorization

Timely submission requirement

Policy Background and Scope

This amendment operationalizes California Insurance Code 10133.56 to provide temporary continuation or completion of covered services when a provider leaves the plan's network or when a newly covered enrollee is already receiving ongoing treatment. It requires the plan to allow continuation of treatment for defined clinical situations (for example, acute conditions, serious chronic conditions, pregnancy and maternal mental health conditions, terminal illness, newborn care, and certain scheduled surgeries), subject to specified documentation, contractual agreement, and timing requirements.

Covered situations include urgent or acute care needs, serious chronic conditions that require ongoing treatment or transfer planning, pregnancy and maternal mental health conditions (with completion of services up to 12 months where specified), terminal illness, care of newborns up to 36 months, and surgeries or procedures authorized to occur within 180 days of contract termination or the member's effective date. Continuation is subject to provider agreement to contractual terms and acceptance of plan payment rates, timely submission of the TOC/COC request, and other eligibility conditions described in the policy.

Key Definitions

Terminated provider — Definition of 'Terminated provider' used in policy

Exact policy definition"Terminated provider" means a provider whose contract to provide services to insureds is terminated or not renewed by the insurer or one of the insurer's contracting provider groups; it does not include a provider who voluntarily leaves the insurer or contracting provider group.

Scope (who is a provider)Provider means 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.

Application contextUsed to determine eligibility for continuity/completion of covered services when a provider's contract is terminated or not renewed.

Maternal mental health condition — Definition describing peripartum and postpartum timeframe and relevance

Definition and timeframeMaternal mental health condition: a mental health condition that can impact a woman during pregnancy, peri- or postpartum, or that arises during pregnancy or in the peri- or postpartum period up to one year after delivery.

OpenPayer

National Clinical Services (NCS) 600 Transition/Continuity of Care Coverage California Traditional Plans

Coverage Criteria — Transition / Continuity of Care

Requested Diagnostic and Procedure Codes

Provider Submission, Documentation, and Operational Requirements

Policy Background and Scope

Key Definitions