CurrentAnthemPolicy N/A

Transition Assistance / Continuation of Care Coverage Requests

Defines Anthem's Transition Assistance and Continuation of Care processes for newly enrolled members seeking to continue care with an out-of-network provider and explains eligibility, examples of qualifying conditions, and how to submit a request.

Policy Summary

PayerAnthem

PolicyTransition Assistance / Continuation of Care Coverage Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTreating provider completes Section 3 with current medical information, signs the form, and faxes the completed form to Medical Management at 877-254-4971.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax: 877-254-4971submission method for completed request form

examples listedqualifying situations

stable chronic conditions excludednon-qualifying examples

signatures requiredauthorization and attestation on form

Continuation of Care Eligibility and Process

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Continuation of Care criteria and submission process

Members may request an exception for Continuation of Care when they are in an active course of treatment for qualifying conditions. The treating provider must complete current medical information, supply supporting documentation, and both member and provider must sign the form.

Eligibility (ALL of the following)

Qualifying clinical situations (ONE or more)
- Active course of treatment for an acute medical condition (sudden onset, limited duration)
- Active course of treatment for a serious medical condition (disease/mental health/substance abuse condition that is serious, persists or worsens, or requires ongoing treatment to maintain remission or prevent deterioration)
- Pregnancy (include estimated delivery date)
- Active course of treatment for cancer
- Transplant care or waiting for transplant
- Terminal illness / Hospice care
Treating provider completes Section 3 (current medical information) with: pertinent diagnosis(es); current and ongoing treatment plan and supporting medical documentation; for hospitalizations or surgeries, a brief statement of inability to transfer care to an in-network provider; estimated delivery date if pregnancy; provider signature and date
Member (or guardian if minor) completes Sections 1 and 2 and provides signature (member/policyholder attestation)

Process (ALL steps must be followed)

Member completes Sections 1 and 2 and signs (guardian signs if member is a minor)
Treating provider completes Section 3/current medical information, supplies diagnoses, current and ongoing treatment plan, supporting documentation, statement of inability to transfer care for hospitalizations/surgeries, signs and dates the form
Fax the completed form to Medical Management at 877-254-4971

Attestation and signatures (ALL required)

Member/policyholder signature
Treating physician/care provider signature and date

Exclusions (NONE of the following qualify)

Routine exams, vaccinations, and health assessments
Elective (non-urgent) inpatient and/or outpatient surgery
Stable chronic conditions not in an acute phase or special course of treatment (examples: diabetes, arthritis, allergies, asthma, hypertension, glaucoma)

Member contact note: If the member's policy is administered through another state, contact the Member Services number on the BCBS/Anthem ID card; special contact instructions apply for certain FEP/SHBP members.

Provider Submission Requirements and How to Submit

Documentation Required

Provider must complete Section 3, sign, include diagnoses/treatment plan, and fax to Medical Management

Treating provider must complete Section 3 (Current Medical Information) of the Continuation of Care/Transition Assistance request form, sign and date the form, and include pertinent diagnoses, the current and ongoing treatment plan with supporting medical documentation; for hospitalizations or surgeries include a brief statement of inability to transfer care to an in‑network provider; if pregnancy, provide an estimated delivery date. Fax the completed form to Medical Management at 877-254-4971.

Complete Section 3: treating physician name, phone, address, fax, signature and date (Section 3).
Attach pertinent diagnosis(es) and current and ongoing treatment plan with supporting medical documentation.
For hospitalizations or surgeries, include a brief statement of inability to transfer care to an in‑network provider.
If pregnancy, provide an estimated delivery date.
Fax the completed form to Medical Management at (877) 254-4971.

Key Definitions

inv-03: Transition Assistance

DefinitionAssistance service for newly enrolled members who wish to continue a relationship with an out-of-network provider they were using prior to enrolling.

ScopeAnthem offers help locating an in-network provider when members request continuation of care after enrollment.

Actionable stepMember should contact Anthem to request Transition Assistance so the plan can help identify an in-network provider or evaluate continuity options.

inv-04: Continuation of Care

DefinitionBenefit allowing continued access to physician services and facilities at in-network coverage levels for specified medical and behavioral conditions for a defined period when clinical reasons prevent immediate transfer of care to another in-network provider.

Eligibility triggerMember is in an active course of treatment for an acute or serious medical condition, pregnancy, active cancer treatment, transplant care, or hospice/terminal illness as clinically appropriate.

LimitationsCoverage is for a defined period and requires documented clinical reasons that prevent immediate transfer of care; routine or stable chronic care is excluded.

inv-05: Acute and Serious medical conditions

Acute medical conditionA condition with sudden onset of symptoms from illness, injury, or other medical problem that requires prompt medical attention and has a limited duration.

Serious medical conditionA disease, illness, mental health or substance abuse condition or other medical problem that is serious in nature, persists without full cure or worsens over time, or requires ongoing treatment to maintain remission or prevent deterioration.

Use in determinationsEligibility for Continuation of Care exceptions depends on being in an active course of treatment for either an acute or serious medical condition.