CurrentBlue Cross Blue Shield - LouisianaPolicy N/A

Request for Benefits for Continuity of Care

This document governs how members of Blue Cross and Blue Shield of Louisiana (and HMO Louisiana, Inc.) may request temporary continuation of benefits to receive care from a provider who has left the network. It affects members, their providers, and Care Management processing these requests.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyRequest for Benefits for Continuity of Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete Part 2 of the Request for Benefits for Continuity of Care form and submit with diagnosis, ICD-10 code, treatment plan, estimated duration, and signatures via fax or mail to Care Management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysmaximum duration of approved continuity of care

1-800-317-2299Care Management phone

1-800-267-6548fax number

5525 Reitz Ave.mailing address

Continuity of Care — Eligibility and Limits

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Continuity of Care qualification and exclusions

Members may qualify for benefits to continue care with an out-of-network provider if one or more of the following conditions apply, subject to exclusions below.

ONE of the following must apply

Undergoing a course of treatment for a serious and complex condition.
Member is in the hospital or under inpatient care.
Member is scheduled for a non-elective surgery or procedure by the provider or is in postoperative care.
Member is pregnant and undergoing a course of treatment for the pregnancy.
Member is terminally ill (life expectancy 6 months or sooner) and undergoing care for the terminal illness from the provider.

Benefits will NOT be approved if any of the following apply

Provider was terminated from the network because the provider's license to practice in Louisiana was suspended or revoked or for another documented reason related to quality of care.
Provider was terminated from the network because of fraud.
Member chooses to change providers.
Member moves out of our geographic service area.
Member does not meet the health conditions listed to qualify for benefits to continue care from an out-of-network provider.

Process notes

If approved, member may continue to see the provider until the course of treatment is complete or 90 days after notification that the provider is leaving the network, whichever comes first.
After review, Blue Cross will notify both the member and the provider of the decision.

Payment terms (if approved)

If approved, provider will be paid under the same terms as the prior agreement and must accept network-level payments; provider may collect applicable member cost-sharing and must not balance-bill beyond the allowable charge.

Provider obligations

Provider must complete Part 2 of the Request for Benefits for Continuity of Care form with diagnosis, ICD-10 code, treatment plan, estimated duration of services, and signatures, and submit the form and supporting records via fax or mail to Care Management for review.

Required Diagnosis Coding and Approval Duration

Required diagnosis codingICD-10

ICD-10

Diagnosis code must be provided by provider on form

inv-03: Approval duration limit

Approval durationUntil the course of treatment is complete or 90 days after Blue Cross notifies the member that the provider is leaving the network, whichever comes first.

Start triggerCount begins from the date Blue Cross notifies the member that the provider is leaving the network or from ongoing course of treatment if earlier.

Maximum numeric limit90 days (maximum approved continuity period when notification has occurred).

Termination of approvalApproval ends upon completion of the provider’s course of treatment or at the 90-day limit, whichever occurs first.

Provider Submission Requirements and Denial Conditions

Prior Authorization

Complete Part 2 of the Continuity of Care form and submit supporting records

Complete Part 2 of the Request for Benefits for Continuity of Care form with the provider's name, contact information, the patient's medical condition, diagnosis and ICD-10 code, the patient's current treatment plan, estimated duration of services, any other providers involved, and the provider's signature and date. Include narratives or copies of medical records that will help Care Management evaluate the request, then submit the completed form and supporting records via fax or mail to Care Management for review.

Provide provider name, mailing address, phone number and signature (Part 2).
List diagnosis and ICD-10 code and describe current treatment plan.
Estimate how long the patient needs services and list other providers involved.
Attach narratives or copies of medical records to support the request.
Fax completed form and records to 1-800-267-6548 or mail to Care Management Services, 5525 Reitz Ave., Baton Rouge, LA 70809.

Denial Risk

Denial triggers for continuity-of-care requests

Benefits will not be approved for continuity of care if the provider was terminated from the network for license suspension or revocation, for quality-of-care reasons, or for fraud; benefits also will not be approved if the member chooses to change providers, moves out of the geographic service area, or does not meet the listed health condition criteria.

Provider termination due to license suspension or revocation or documented quality-of-care reasons prevents approval.
Provider termination for fraud prevents approval.
Member-driven changes (choosing a new provider) or relocation outside the service area will result in denial.
Requests where the member does not meet the health condition criteria on the form will be denied.

Key Definitions

inv-06: provider who is no longer in the network

TermOut-of-network provider

DefinitionA provider who is no longer in Blue Cross and Blue Shield of Louisiana’s network (a provider who has left the network).

Context of useUsed when determining member eligibility for temporary continuation of benefits to receive services from that provider.

Related processMembers must submit the Request for Benefits for Continuity of Care for review by Care Management.

inv-07: life expectancy is 6 months or sooner

TermTerminally ill

DefinitionLife expectancy is 6 months or sooner and the member is undergoing care for the terminal illness from the provider.

RelevanceMeets one of the qualifying conditions for approval of continuity-of-care benefits.

DocumentationProvider must document diagnosis and course of treatment on the Request for Benefits for Continuity of Care form for review.