Continuity of Care benefits request process
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Governs the process for BCBSND members to request continuation of covered services from an out-of-network provider for specific clinical situations; affects BCBSND members and their treating providers in North Dakota.
Continuity of Care Eligibility and Process
Continuity of Care request criteria and process
Members may be eligible for Continuity of Care benefits if they meet any qualifying condition in Section 1 and complete the required form sections; provider input is required when Section 1 contains any YES responses.
ONE of the following qualifying conditions (Section 1)
- Member is at least 3 months pregnant or delivered in the past 6 weeks and answers YES to that question
- Member is pregnant and provider has identified the pregnancy as high-risk (Section 1 question)
- Member is currently receiving non-surgical cancer treatment (radiation or chemotherapy); if yes provide date of last treatment
- Member is currently receiving surgical cancer treatment; if yes provide date of last surgery
- Member is receiving active treatment for HIV/AIDS; if yes provide date of last treatment
- Member is receiving active treatment for severe or end-stage kidney disease or dialysis; if yes provide date of last treatment
- Member is on a waiting list to obtain an organ; if yes provide date of last treatment
- Member is currently receiving inpatient services at a facility; if yes provide facility name and date of admission
- Member is currently receiving outpatient or inpatient mental health or substance use services by a licensed mental health provider; if yes provide provider name and date last seen
- Member is receiving treatment for a serious or terminal condition, non-elective surgery, or other life‑threatening condition not described above; if yes provide provider name, date last seen, and detailed description of the condition
Section 2 collects required member details before submission
ALL of the following
- Provide provider name, NPI, phone, fax, address, city, state, zip
- Provide date of last visit and date of next scheduled appointment
- Provide frequency of visits, diagnosis, expected length of treatment
- If maternity, provide expected date of delivery
- Provide facility name and current and planned treatment/comments
- Provider must sign Section 3 (clinical information and signature)
BCBSND will notify the member of approval or denial after review
Codes and Eligibility Trigger
| No billing or procedure codes are specified on the form. |
Provider Responsibilities and Submission
Provider completion and signature
Provider must complete Section 3 of the Continuity of Care form when the member answers YES to any condition in Section 1. Section 3 must include clinical information: provider name, NPI, contact info, dates of last visit and next scheduled appointment, frequency of visits, diagnosis, expected length of treatment (and if maternity, expected date of delivery), facility name, and current/planned treatment/comments — and the provider must sign the form.
- Include Date Of Last Visit and Date Of Next Scheduled Appointment.
- Document Diagnosis, Frequency Of Visits, Expected Length of Treatment (and Expected Date of Delivery if maternity).
- Provide Provider Name, Provider NPI, Phone, Fax, Address, City, State, Zip, and Facility Name.
- Complete Current and Planned Treatment/Comments and sign Section 3 before submission.
Submission and review — signatures and where to send
Both the member and the treating provider must sign the completed form and submit it to Continuity of Care Utilization Management for BCBSND review and decision. Submit by mail to Blue Cross Blue Shield of North Dakota, ATTN: Continuity of Care Utilization Management, 4510 13th Avenue South, Fargo, ND 58121-0001, or fax to (701) 277-2253.
- Member and provider signatures are required prior to submission.
- Mailing address: 4510 13th Avenue South, Fargo, North Dakota 58121-0001.
- Fax number: (701) 277-2253.
Terms and Qualifying Situations
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