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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAmeriHealth LA Care Continuity Update | OpenPayer
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    CurrentAmeriHealth Caritas LouisianaPolicy N/A

    Continuity of Care

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    This policy governs continuity and coordination of medically necessary care for ACLA enrollees transitioning into or out of the plan, changing providers, or receiving care from non-participating providers. It establishes special protections for newly enrolled pregnant women, current enrollees with ongoing treatment, transitions between MCOs or Medicaid FFS, and related administrative and privacy processes.

    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyContinuity of Care
    Policy CodePolicy N/A
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateFeb 22, 2023
    Last ReviewNov 7, 2022
    Next Review DateNov 7, 2023
    Key ActionContinue medically necessary covered services for newly enrolled pregnant women for up to 90 calendar days or until care can be transferred without disruption, whichever is less.
    SourceLink
    POLICY UPDATE CHANGES

    The December 2022 revision updated references from member to Enrollee, updated contract reference sections, and revised Policy 2 contract language.

    The December 2022 revision added Policy 7 behavioral health collaboration language involving OJJ, DCFS, DOE, nursing facilities, and the Department of Corrections.

    The December 2022 revision added statements assigning ACLA responsibility for coordination and continuity of care consistent with 42 CFR §438.208 and for integrating physical and behavioral health services.

    90 daysMaximum continuation period for many newly enrolled members and DME before transfer

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    60 days postpartum
    Prenatal continuation for second- or third-trimester enrollees
    30 daysInitial new-member period without medical necessity review
    15 daysProvider termination notification deadline

    Continuity of Care Eligibility

    Newly Enrolled Pregnant Women

    Continuation protections apply based on the type of medically necessary care and the pregnant Enrollee's trimester at enrollment.

    ONE of the following applies

    • Non-prenatal medically necessary services

      • The newly enrolled pregnant Enrollee was receiving medically necessary covered services other than, or in addition to, prenatal services when becoming an ACLA Enrollee.
      • ACLA covers continuation of those services regardless of whether the Practitioner/Provider is participating or non-participating.Up to 90 calendar days or until reasonable transfer without disruption, whichever is less
      • ACLA may require prior authorization for continuation beyond 30 calendar days, but may not deny authorization solely because the Practitioner/Provider is non-contracted.

    • First trimester prenatal care

      • The Enrollee was in the first trimester and receiving medically necessary covered prenatal care the day before becoming an ACLA Enrollee.
      • The Enrollee may continue medically necessary prenatal care, including delivery and post-natal care, without prior authorization and regardless of whether the Practitioner/Provider is participating or non-participating.
      • Continuation remains available until ACLA can reasonably transfer the Enrollee to a participating Practitioner/Provider without impeding delivery in a manner that could harm the Enrollee's health.

    • Second- or third-trimester prenatal care

      • The Enrollee was in the second or third trimester and receiving medically necessary covered prenatal care the day before becoming an ACLA Enrollee.
      • The Enrollee may continue receiving services from the prenatal care Practitioner/Provider, whether participating or non-participating.60 calendar days postpartum
      • The Enrollee remains eligible for Medicaid; if eligibility terminates before the postpartum period ends, ACLA will refer the Enrollee to a safety-net provider.

    Transition and Provider-Termination Continuity

    ACLA provides transition and provider-termination protections when interruption of care could cause serious detriment to the Enrollee's health or increase the risk of hospitalization or institutionalization.

    ONE of the following transition protections applies

    • Transition between MCOs while hospitalized

      • The Enrollee is transferred between MCOs while hospitalized.
      • The transfer is effective on the date of enrollment into the receiving MCO; the relinquishing MCO remains responsible for the hospitalization until discharge, and the receiving MCO is responsible for all other care.

    • Transition of care between an MCO and another MCO or Medicaid FFS

      • ACLA actively assists the Enrollee in transitioning to or from another MCO or Medicaid fee-for-service under a transition-of-care process that ensures continued access to services when interruption could cause serious detriment to health or risk hospitalization or institutionalization.

    Continuation Periods and Operational Limits

    Non-prenatal services
    Covered populationNewly enrolled pregnant women receiving medically necessary covered services other than prenatal services at enrollment.
    Continuation periodUp to 90 calendar days or until the Enrollee may be reasonably transferred without disruption, whichever is less.
    Prior authorizationACLA may require prior authorization after 30 calendar days, but may not deny authorization solely because the provider is non-contracted.
    First-trimester prenatal care
    Covered populationNewly enrolled pregnant women in the first trimester who were receiving medically necessary covered prenatal services the day before enrollment.
    Services continuedPrenatal care, delivery, and post-natal care may continue without prior authorization and regardless of provider participation.

    Required Transition and Continuity Actions

    Note

    Newly Enrolled Pregnant Women: Non-Prenatal Services

    When a newly enrolled pregnant woman is receiving medically necessary covered services other than prenatal services at enrollment, continue coverage for up to 90 calendar days or until she can be reasonably transferred without disruption, whichever is less. Prior authorization may be required after 30 calendar days, but authorization may not be denied solely because the provider is non-participating.

    • Apply this protection to medically necessary covered services provided by participating or non-participating practitioners/providers.
    • Coordinate a disruption-free transfer when appropriate.
    Note

    First-Trimester Pregnancy Continuity

    For a newly enrolled woman in the first trimester who was receiving medically necessary covered prenatal services immediately before enrollment, continue medically necessary prenatal care without prior authorization and without regard to provider participation until ACLA can reasonably transfer her to a participating provider without impeding a delivery that could harm her health.

    • Include prenatal care, delivery, and post-natal care.
    • Do not impose a prior authorization requirement during this protected transition period.

    Key Terms

    Ongoing course of treatment
    DefinitionTreatment for a chronic or acute medical condition, a behavioral health condition, or a life-threatening illness.
    Medical conditionsIncludes both chronic and acute medical conditions.
    Additional conditionsAlso includes behavioral health conditions and life-threatening illness.
    Incidental use or disclosure
    DefinitionA secondary use or disclosure of protected health information.
    Preventability and scopeThe use or disclosure cannot reasonably be prevented and is limited in nature.
    Relationship to permitted activity
    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyContinuity of Care
    Policy CodePolicy N/A
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateFeb 22, 2023
    Last ReviewNov 7, 2022
    Next Review DateNov 7, 2023
    Key ActionContinue medically necessary covered services for newly enrolled pregnant women for up to 90 calendar days or until care can be transferred without disruption, whichever is less.
    SourceLink
    On This Page
    Continuity of Care EligibilityContinuation Periods and Operational LimitsRequired Transition and Continuity ActionsKey Terms
  1. The Enrollee has access consistent with prior access and may retain a current non-network provider.30 days
  2. ACLA coordinates with the relinquishing MCO so services are not interrupted and arranges referrals to appropriate in-network providers for continuity of necessary care.
  3. The accepting MCO receives necessary medical records; record reproduction and forwarding costs are the responsibility of the relinquishing contractor, and providers may contact ACLA's UM department to obtain records as appropriate.
  4. ACLA coordinates other procedures specified by LDH in writing and complies with applicable federal and state law.
  5. Special consideration is given to Enrollees with significant conditions or treatments, including enteral feedings, oxygen, wound care, ventilators, medical supplies, scheduled transportation, chemotherapy or radiation therapy, hospitalization, scheduled or previously authorized surgeries, post-surgical follow-up, post-transition therapies, out-of-area specialty care, ongoing monitoring or screening needs, elevated blood lead levels, prematurity, high-risk pregnancy, pregnancy within the prior 30 days, organ or tissue transplantation needs, or chronic illness resulting in hospitalization.

  6. Provider contract termination—ongoing treatment

    • A current Enrollee is receiving an ongoing course of treatment for a chronic or acute medical condition, behavioral health condition, or life-threatening illness from a Practitioner/Provider whose contract with ACLA is terminated by ACLA or the Practitioner.
    • The Enrollee may continue the ongoing course of treatment.Up to 90 calendar days from the effective date of termination

    • Coverage does not continue if

      • ACLA terminated the Practitioner/Provider contract as the result of a professional review action involving a quality-of-care issue.
      • The Practitioner/Provider is unwilling to continue treating the Enrollee or to accept ACLA's payment or other terms.

  7. Provider contract termination—pregnancy

    • On the date ACLA notifies a current Enrollee of a termination or pending termination, the Enrollee is in the second or third trimester or is identified as having a high-risk pregnancy.
    • The Enrollee may continue an ongoing course of treatment with a non-participating obstetrician or midwife through completion of postpartum care related to the delivery.

    • Coverage does not continue if

      • ACLA terminated the Practitioner/Provider contract as the result of a professional review action involving a quality-of-care issue.
      • The Practitioner/Provider is unwilling to continue treating the Enrollee or to accept ACLA's payment or other terms.
    8. Transfer standardCare continues until ACLA can reasonably transfer the Enrollee to a participating provider without impeding delivery in a manner harmful to the Enrollee’s health.
    Second- or third-trimester prenatal care
    Covered populationNewly enrolled pregnant women in the second or third trimester who were receiving medically necessary covered prenatal care the day before enrollment.
    Continuation periodServices may continue with the existing prenatal provider, whether participating or non-participating, for 60 calendar days postpartum while the Enrollee remains Medicaid eligible.
    Eligibility ends earlyIf Medicaid eligibility ends before the postpartum period is complete, refer the Enrollee to a safety-net provider.
    General new-member transition
    Covered populationNewly enrolled members who were receiving medically necessary covered services the day before becoming an ACLA Enrollee.
    Initial no-review periodServices may continue for the first 30 calendar days of enrollment without medical necessity review.
    After 30 daysApplicable prior authorization requirements apply to services requiring authorization; medically necessary services may continue for up to an additional 30 calendar days or until reasonably transferable without disruption, whichever is less.
    DME and related supplies
    Covered itemsMedicaid-covered durable medical equipment, prosthetics, orthotics, and certain supplies received at enrollment from another MCO or Medicaid fee-for-service.
    Continuation periodContinue without prior authorization and regardless of provider participation for up to 90 calendar days or until reasonably transferable without disruption, whichever is less.
    Existing authorizationHonor prior authorizations issued by another MCO or Medicaid fee-for-service for 90 calendar days after enrollment into ACLA.
    Authorized quantity and scopeHonor the authorized quantity and scope of services for 30 calendar days from the Enrollee’s effective ACLA enrollment date.
    Provider-termination continuity
    Covered populationCurrent Enrollees receiving an ongoing course of treatment from a Practitioner or Provider whose ACLA contract terminates.
    Continuation periodThe ongoing course of treatment may continue for up to 90 calendar days from the effective date of termination.
    Pregnancy-related provisionAn Enrollee in the second or third trimester or identified as having a high-risk pregnancy may continue treatment with a non-participating obstetrician or midwife through completion of postpartum care related to the delivery.
    ExceptionsContinuation is not provided when ACLA terminated the contract for a professional review or quality-of-care issue, or when the provider will not continue treatment or accept ACLA payment or other terms.
    Note

    Second- or Third-Trimester Pregnancy Continuity

    For a newly enrolled woman in the second or third trimester who was receiving medically necessary covered prenatal care immediately before enrollment, continue care with the existing prenatal provider, whether participating or non-participating, through 60 calendar days postpartum while Medicaid eligibility continues.

    • If Medicaid eligibility ends before the postpartum period concludes, refer the member to a safety-net provider.
    • Continue prenatal, delivery, and related postpartum care without disrupting delivery or medically necessary treatment.
    Note

    General New-Member Transition Period

    For any newly enrolled member receiving medically necessary covered services immediately before enrollment, continue those services for the first 30 calendar days without medical-necessity review and regardless of provider participation. After that period, apply prior authorization requirements where applicable and continue medically necessary coverage for up to an additional 30 calendar days or until a disruption-free transfer is reasonably possible, whichever is less.

    • Do not deny authorization solely because the practitioner/provider is non-participating.
    • Identify services requiring prior authorization after the initial 30-day period.
    Prior Authorization

    DME, Prosthetics, Orthotics, and Supplies

    For Medicaid-covered durable medical equipment, prosthetics, orthotics, and certain supplies received at enrollment from another MCO or Medicaid fee-for-service, continue coverage without prior authorization and regardless of provider participation for up to 90 calendar days or until a disruption-free transfer is reasonably possible, whichever is less.

    • Honor prior authorization issued by another MCO or Medicaid fee-for-service for 90 calendar days after ACLA enrollment.
    • When identified by a provider, honor the authorized quantity and scope of DME, prosthetics, orthotics, and medical supplies for 30 calendar days from the effective enrollment date.

    Unsupported block type: prior_auth

    Note

    Provider Termination Continuity

    Allow a current enrollee receiving an ongoing course of treatment from a provider whose ACLA contract terminates to continue that treatment for up to 90 calendar days from the effective termination date.

    • Apply to chronic or acute medical conditions, behavioral health conditions, and life-threatening illnesses.
    • Do not provide continuation when ACLA terminated the contract for professional review or quality-of-care reasons, or when the provider will not continue treatment or accept ACLA payment or other terms.
    Note

    Pregnancy-Related Provider Termination

    When a current enrollee is in the second or third trimester or has a high-risk pregnancy, allow continuation of an ongoing course of treatment with a non-participating obstetrician or midwife from the termination notice date through completion of postpartum care related to the delivery.

    • The same exceptions apply when the provider was terminated for professional review or quality-of-care reasons or refuses to continue treatment or accept ACLA payment or other terms.
    • Coordinate care with the member and provider to avoid disruption through delivery and postpartum care.
    Note

    MCO and Medicaid FFS Transition Coordination

    Provide active transition assistance when interruption of services could seriously harm an enrollee or create a risk of hospitalization or institutionalization. Coordinate with the relinquishing MCO or Medicaid fee-for-service and preserve access consistent with the member’s prior access.

    • For members transferring between MCOs while hospitalized, the relinquishing MCO remains responsible for the hospitalization until discharge; the receiving MCO is responsible for other care.
    • Permit the enrollee to retain a current out-of-network provider for 30 days and arrange referrals to appropriate in-network providers.
    • Give special consideration to high-risk pregnancy, recent pregnancy, chronic illness, complex treatments, scheduled procedures, ongoing monitoring, and other significant conditions.
    • Coordinate records, utilization history, case management files, and other procedures required by LDH.
    Documentation Required

    Transition Report and Authorization Workflow

    Review the LDH transition report monthly to identify members transitioning from another MCO or Medicaid fee-for-service. Request open authorization information from the relinquishing plan and enter continuation authorizations into the ACLA authorization system for the applicable transition period.

    • Obtain and review historical utilization data, medical records, and case management files as needed.
    • Provide records and authorization information to the accepting MCO or Medicaid fee-for-service upon request.
    • Enter continuation authorizations for services meeting the transition-of-care guidelines.
    Documentation Required

    Provider Termination Notification

    When a provider contract is terminated or is pending termination and continuity rights apply, identify affected enrollees and notify each enrollee by letter within 15 calendar days after receiving the provider’s termination notice.

    • Explain the provider’s termination and effective date, the member’s ability to continue services, and how to access those services.
    • For terminating PCPs, identify the assigned replacement PCP and explain the process and the 10-business-day window to select a different PCP.
    • For terminating specialists, advise the member to contact the PCP about ongoing needs and transition to another participating specialist.
    Billing Rule

    Member Billing and PHI Safeguards

    Do not bill enrollees receiving ongoing treatment for the costs of medically necessary core benefits and services. Protect PHI and use, request, or disclose it only as permitted for treatment, payment, or health care operations and consistent with minimum-necessary and safeguarding requirements.

    • Do not seek member authorization for PHI uses or disclosures for TPO when HIPAA does not require it.
    • Limit PHI to the minimum necessary, apply administrative, technical, and physical safeguards, and protect against unauthorized or incidental use or disclosure.
    • Follow applicable safeguards for faxed or otherwise transmitted PHI.
    It occurs as a by-product of an otherwise permitted use or disclosure.