Aetna transition/continuity of care Coverage

When Transition / Continuity of Care Is Covered

inv-01: Conditions eligible for completion of covered services

Covered when ANY one of the following conditions applies and other procedural/contractual requirements are met:

Acute condition: An acute condition: sudden onset of symptoms due to an illness, injury, or other medical, mental health or substance use problem that requires prompt medical attention; completion of covered services will be provided for the duration of the acute condition.duration = acute episode

Serious chronic condition: a disease, illness, or other medical, mental health or substance use problem that is serious in nature, persists without full cure, worsens over time, or requires ongoing treatment to maintain remission or prevent deterioration; completion of covered services will be provided for the period necessary to complete the course of treatment and arrange a safe transfer, not to exceed 12 months from the provider's contract termination date or from the effective date for a newly covered enrollee.<= 12 months

Pregnancy and maternal mental health: Pregnancy: the three trimesters and the immediate postpartum period; completion of covered services will be provided for the duration of pregnancy and immediate postpartum. Maternal mental health condition: a mental health condition impacting a woman during pregnancy, peri- or postpartum, or arising 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 is later.<= 12 months as specified

Terminal illness: an incurable or irreversible condition with a high probability of causing death within one year or less; completion of covered services will be provided for the duration of the terminal illness.duration = terminal illness

Newborn care (0–36 months): Care of a newborn between birth and age 36 months; completion of covered services shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee.<= 12 months

Authorized surgery or procedure: Performance of a surgery or other procedure that is authorized by the plan as 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.<= 180 days

inv-02: Eligibility / Covered situations

Covered when the member meets the definition of an active course of treatment or other qualifying situation; coverage is time-limited as specified below.

Qualifying situations for TOC/COC: Member is eligible if any one of the following applies: (1) pregnant and has begun a course of treatment (including prenatal care); (2) diagnosed with a maternal mental health condition (coverage up to 12 months from diagnosis or end of pregnancy, whichever is later); (3) has an acute condition with sudden onset requiring prompt attention (coverage for duration of acute condition); (4) authorized to undergo surgery or procedure with documentation that the provider recommends treatment to occur within 180 days of the provider's contract termination date or within 180 days after the effective date for a newly covered enrollee; (5) has a terminal illness (coverage for duration of illness); (6) has an ongoing disabling medical condition or serious/chronic mental illness requiring ongoing treatment (coverage necessary to complete course and arrange safe transfer, not to exceed 12 months from contract termination or effective date); (7) undergoing chemotherapy or radiation therapy; (8) receiving services related to care of a child ages 0–36 months (up to 12 months from contract termination or effective date); (9) may need or have had an organ or bone marrow transplant.

inv-03: Benefit level and continuation

Limits and benefit level during TOC/COC:

Post-approval benefit limits: If TOC/COC coverage is approved, the member may receive care at the highest benefit level only for a limited period. Continued treatment beyond the approved period may be subject to the plan's regular benefit limitations (which could result in reduced benefits or no benefits depending on the member's plan/network).

The plan is not required to provide continuation of covered services when the provider's contract was terminated or not renewed for reasons related to medical disciplinary causes, fraud, or other criminal activity. Additionally, services will not be continued if the terminated or nonparticipating provider does not agree to the contractual terms and conditions required by the plan (including credentialing, privileging, utilization review, peer review and quality assurance), or if the provider does not accept the payment rates offered by the plan. These contractual conditions derive from California statutory and policy requirements and may be enforced before approving Transition of Care/Transition Coverage (TOC/COC) requests.

Requests for TOC/COC will be denied when the requested procedure or service is not a covered benefit under the member's plan. Separately, continuation is not required where coverage would continue only if the departing provider agrees to the plan's terms; if the provider refuses those terms (including accepting the payment rates specified), the plan is not obligated to continue services. Providers and requesters should confirm benefit coverage before submitting a TOC/COC Request.

Requested Diagnostic and Procedure Codes (Form Fields)

Requested diagnostic and CPT/HCPCS codes (form fields)mixed

DX:	Diagnosis code field as listed on the form
CPT/HCPCS:	Procedure code field as listed on the form

Diagnostic and CPT/HCPCS Codes (form fields)mixed

DX: (diagnosis) and CPT/HCPCS fields present on form

Diagnostic and CPT/HCPCS Codes (additional form fields)mixed

DX: (diagnosis) and CPT/HCPCS fields present on form

Surgical follow-up coding fieldsmixed

DX: (diagnosis) and CPT/HCPCS fields present on surgical follow-up section

Obstetrical coding fieldsmixed

DX: (diagnosis) and CPT/HCPCS fields present on obstetrical section

inv-11: Recent oncology treatment — treatment initiated in the last 90 days

Recent oncology treatment thresholdTreatment initiated in the last 90 days

Oncology treatment types listed on formReconstruction surgery, radiation therapy, immunotherapy, targeted agents, or chemotherapy

Form fields required for oncology requestsName of drug, diagnosis and description, expected length of treatment, visit and next visit dates

Forms, Submission, and Provider Responsibilities

Documentation Required

Form and signatures required

Completed TOC/COC Request Form with required signatures (patient or parent and treating provider) must be submitted. The patient (age 17 or older) or parent (if patient is 16 or younger) must sign the Authorization section; the treating provider must complete and sign the Provider Information section and relevant treatment sections.

Patient signature required if patient is 17 or older; parent signature required if patient is 16 or younger.
Treating provider must sign and date the provider signature field on the form.

Prior Authorization

Submission time limits

Submit the TOC/COC Request form within 90 days of enrollment or re‑enrollment, within 90 days of the date the provider left the network or of the notice of the change, or within 90 days of a provider's network status change. The plan may make exceptions for extenuating circumstances.

Key Definitions

inv-29: Nonparticipating provider — definition

DefinitionA nonparticipating provider is a provider who is not contracted with a health care service plan (CA Health & Safety Code 1373.96(n)(3)).

ScopeIncludes individual clinicians, facilities, and other persons or institutions that are not under contract with the plan.

Implication for TOC/COCEligibility for transition/continuity coverage may apply when a member is receiving care from a nonparticipating provider, subject to policy criteria and contractual terms.

inv-30: Individual provider — definition

DefinitionAn individual 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 (CA Health & Safety Code 1373.96(n)(1)).

Examples

Admission Criteria for Facility-Level Services

inv-32: SNF | home health | participating hospitals — admission criteria

Facility/provider types eligible: TOC/COC coverage may apply to participating hospitals (when the facility is not designated for the highest benefit level or when a participating facility terminates from the network) and to providers such as physical therapists, occupational therapists, speech therapists, and agencies that provide skilled home care services (e.g., visiting nurses).

Criteria for Continued Stay / Ongoing Coverage

inv-33: Continued stay criteria

Provider obligations if approved: If the request is approved, the treating (nonparticipating or terminated) provider must: provide the patient's treatment and follow-up; not seek additional payment from the patient beyond applicable patient responsibility under the plan; share treatment information with the plan; and use the health plan's network for referrals, lab work, or hospitalizations for services not part of the requested treatment, as documented on the provider form.

Discharge Criteria and Limits

Discharge from TOC/COC occurs when the member's authorized course of treatment is complete and arrangements have been made for a safe transfer to another provider. Completion is determined by the health plan in consultation with the enrollee and the terminated or nonparticipating provider and must be consistent with good professional practice. The authorization is valid only for a limited period as stated on the approval and the plan may request medical records to make a final determination.

When approved, the treating (terminated or nonparticipating) provider must provide the patient's treatment and follow-up until discharge, shall not seek additional payment beyond the member's responsibility under the plan, and must share treatment information with the plan. The provider also agrees to use the health plan's network for referrals, lab work, or hospitalizations for services not part of the authorized treatment. These obligations inform the plan's assessment of when a safe transfer and discharge can occur.

Time Limits for Completion of Services

inv-36: 180 days from contract termination or effective date — surgical/postoperative care eligibility window

Surgical/postoperative eligibility windowSurgery or other authorized procedures 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 to be eligible for completion of services.

Applies toAuthorized surgeries or procedures that are part of a documented course of treatment, including postoperative care.

Documentation requirementDocumentation must show the provider recommends the treatment to occur within the 180-day window.

inv-37: Completion of services shall not exceed 12 months (where specified)

Maximum completion period where specifiedCompletion of covered services shall not exceed 12 months from the provider's contract termination date or 12 months from the effective date for a newly covered enrollee (where specified).

Policy Background

This policy ensures continuity and completion of covered medical, mental health, and substance use services when a provider's network status changes or when a member is newly covered but already receiving an active course of treatment from a nonparticipating provider. Eligible situations include acute conditions, serious chronic conditions, pregnancy (including maternal mental health), terminal illness, newborn care up to 36 months, chemotherapy/radiation, and authorized surgeries or procedures that meet timing requirements. Coverage is time-limited and determined in consultation with the enrollee and provider, with specific maximum periods described elsewhere in the policy.

OpenPayer

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