National Clinical Services (NCS) 600 — Transition/Continuity of Care Coverage (California Traditional Plans)
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Amendment to Aetna's NCS 600 specifying California-specific transition/continuity of care (TOC/COC) requirements that apply to fully insured traditional (non‑HMO) commercial plans and certain departments and products within the plan.
No material clinical or coverage changes in this revision.
Transition / Continuity of Care Coverage Criteria
Covered condition categories
The plan shall provide completion of covered services for members receiving care from a terminated or nonparticipating provider when any of the following condition categories apply:
Applied when member was receiving services at time of provider termination or at time coverage became effective for newly covered enrollee.
Timing, submission, and provider agreement
Coverage applies when the member was receiving treatment from the provider at the time of contract termination (terminated provider) or at the time coverage became effective (nonparticipating provider/new enrollee), subject to submission timelines and provider agreement requirements:
Form completion requirements and timelines described in Exhibit 1 and policy text; provider must sign and agree to terms on form.
Temporary Transition/Continuity Coverage Criteria
Covered temporarily when ALL of the following are met:
Authorization section and permission to obtain records required on the form.
Specific form sections for oncology, IV therapy, surgical follow-up, obstetrical, and other requests (dates, expected length/end date, and codes).
Provider information and signature required on the form; provider must agree to specified conditions.
The TOC/COC provisions do not apply to vendors that supply durable medical equipment (DME) or to pharmaceutical items. If TOC/COC is approved for care involving DME or medications, the treating provider must use a DME vendor or pharmacy vendor in the plan's network. Additionally, the plan is not required to continue services when the services themselves are not covered under the terms and conditions of the insurer contract, or when the terminated provider was removed for medical disciplinary reasons, fraud/criminal activity, or the provider refuses contractual terms or payment rates specified by the plan.
TOC/COC coverage does not apply when the health plan does not maintain a provider network. Members should contact Member Services for questions about coverage options; approval decisions will be communicated by U.S. mail.
The plan is not required to continue or complete services that are not otherwise included as covered benefits under the insurer's contract. In other words, services not covered under the plan's terms and conditions are excluded from TOC/COC obligations.
Settings and Admission-Related Criteria
SNF | acute hospital | licensed institution
Facility and provider types considered for TOC/COC admissions:
Providers considered may vary by condition; exclusions for DME/pharmacy noted.
Time Limits for Transition Coverage
Form Fields: Diagnostic and Procedure Codes
| DX | Placeholder field for diagnosis code as requested on form |
| CPT/HCPCS | Placeholder field for CPT or HCPCS procedure codes as requested on form |
Provider Submission, Documentation, and Obligations
Submission and provider completion
Step 1: Complete Sections 1–3 and sign the authorization. Then give the form to the treating provider to complete Section 4 (provider information) and the diagnostic/treatment details on the subsequent pages. Providers must complete Section 4 and include all diagnostic and CPT/HCPCS codes and clinical documentation requested to avoid delays. One form must be submitted for each provider.
- Complete Section 1 (plan info), Section 2 (subscriber/patient info), Section 3 (authorization) and sign/date where required.
- Provider completes Section 4 and the diagnostic/treatment fields; include CPT/HCPCS and DX codes and attach clinical records.
- Submit one form per provider. Fax to 1-859-455-8650, mail to the address on the member ID card, or upload via Aetna member website Message Center.
Authorization and medical records
The form includes an authorization the patient (or parent if required) must sign to permit the treating provider to send medical records. Providers must supply requested medical records and attachments (diagnostic, treatment plan, operative dates, EDC for pregnancy, expected start/end dates for therapies) so the plan can make a timely decision.
- Patient/parent signature required (patient age-dependent).
- Attach clinical documentation supporting the active course of treatment, including dates and expected end dates where applicable.
- Provide brief statement of current condition and treatment plan; for pregnancy include estimated date of confinement (EDC).
Provider termination documentation
If the request is due to provider termination, the form requires the date of the termination notice and a copy of the termination letter be attached. Failure to include provider termination documentation may delay processing.
- Indicate provider termination on the form and provide the date of the termination notice (MM/DD/YYYY).
- Attach the provider termination letter with the completed form.
Prior authorization not specified
The form and source chunks do not specify any additional prior authorization requirements beyond submitting the Transition/Continuity Coverage Request; specific billing or prior authorization codes are not enumerated in these sections.
- No explicit prior authorization list or affected billing codes are provided in these form instructions.
- Decisions are made after receipt of the completed request and supporting records; if services occurred prior to approval the Medical Director must review for coverage.
Denial triggers
The plan is not required to continue services if the provider was terminated or not renewed for disciplinary reasons, fraud, criminal activity, or if services are not covered under the plan contract. Also, continuation is not required if the terminated provider refuses to comply with contractual terms or payment rates.
- Denial or non-continuation may occur for provider termination for medical disciplinary cause, fraud, or criminal activity.
- Plan may deny continuation for services not covered under the plan contract.
- No continuation if the terminated provider will not accept plan payment rates or comply with contractual terms.
Denial / benefit limitation risk
If TOC/COC approval is not granted or the approved time period ends, continuation of care may be limited to whatever the member's plan allows; this can result in reduced benefits or no benefits for ongoing services. Services received before approval may require Medical Director review for coverage.
- If TOC/COC is not approved or expires, coverage may be limited to plan allowances and result in reduced or no benefits.
- Services provided prior to approval require Medical Director review to determine if coverage can be extended at plan level.
No explicit authorization or denial triggers in these chunks — process and notices emphasized
The decision timeline and notice process are described: decisions are made within two business days after all necessary information is received; the provider is notified telephonically within 24 hours of decision and the member and terminated provider in writing within two business days.
- Plan decisions within 2 business days of receiving all required information.
- Provider notified by phone within 24 hours; member and terminated provider notified in writing within 2 business days.
Required documentation and timelines
Providers must supply required documentation and adhere to timelines to avoid delay: completed Transition/Continuity Coverage Request (Exhibit/TOC form), diagnostic/treatment information, CPT/HCPCS and DX codes, and any supporting clinical records relevant to the active course of treatment.
- Completed form (all applicable sections) and attached clinical documentation.
- Include diagnostic and CPT/HCPCS codes in the diagnostic fields.
- Provide operative dates, therapy start/end dates, expected end dates, and any other supporting records as applicable.
Required provider documentation
Provider-identifying information and attestations required on the form include provider name, Tax ID, service address, contact name and telephone, signature and date, and a statement of medical necessity/current treatment plan. Providers also must agree not to seek additional payment beyond member responsibility and to share treatment information with the plan.
- Provider name, Tax ID, service address, office contact and telephone.
- Provider signature and date required on Section 4.
- Brief statement of patient's current condition and treatment plan; attestation not to seek additional payment beyond patient responsibility and to share treatment information with the plan.
Network use for related services
If TOC/COC is approved for an outside or nonparticipating provider, that provider agrees to use the plan's network for referrals, labs, and hospitalizations for services not part of the requested treatment. DME vendors and pharmacies are excluded from TOC/COC; when TOC is approved, the treating doctor must use in-network DME and pharmacy vendors.
- Approved outside provider must use the health plan's network for referrals, labs, and hospitalizations not part of the requested treatment.
- TOC/COC does not include DME vendors or pharmaceuticals; approved TOC requires use of in-network DME and pharmacy vendors.
Key Term Definitions
Policy Background and Scope
This amendment implements California Insurance Code 10133.56 by defining the conditions under which temporary continuation or continuity of care (TOC/COC) must be offered. Qualifying situations include acute conditions, serious chronic conditions, pregnancy and postpartum care (including maternal mental health conditions), terminal illness, and newborn carerecommended to occur within 180 days of contract termination or the effective date of coverage for a newly enrolled member. For certain categories—serious chronic conditions, newborn care, and maternal mental health—the plan may allow completion of care for up to 12 months from the contract termination date or effective coverage date, consistent with the statute.
Coding, Legal Notices, and Warnings
Provide requested diagnostic and CPT/HCPCS codes and comply with California legal notice
The form asks for diagnostic and CPT/HCPCS codes in multiple diagnostic sections and includes a California legal notice warning that knowingly presenting a false or fraudulent claim is a crime subject to fines and imprisonment.
- Fill in DX and CPT/HCPCS code fields in the form's diagnostic sections.
- Be aware of the California misrepresentation statement on the form.
Form Submission Deadlines and Decision Timelines
Policy Revision History
Policy amendment became effective for California Traditional Plans to implement California Insurance Code 10133.56 requirements for transition/continuity of care coverage.
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