CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

Continuity of Care request process

This document governs BCBSND members' eligibility, request, and submission process to continue receiving covered services from an out-of-network provider for specified clinical situations; it affects BCBSND members and their treating providers.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyContinuity of Care request process

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionMember completes Sections 1 and 2 and the treating provider completes and signs Section 3 before submitting the form for BCBSND review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10eligibility screening questions in Section 1

4510 13th Ave Smailing address for submission

Fax: (701) 277-2253fax number for form submission

1-844-363-8457Member Services phone

Continuity of Care Eligibility

Continuity of Care eligibility and submission

Eligibility is determined by an affirmative answer to ANY question in Section 1 plus completion of Section 3 by the treating provider with supporting documentation and signatures.

ONE of

Member answers YES to any Section 1 question: at least 3 months pregnant or delivered <6 weeks ago
Member answers YES to high‑risk pregnancy (Section 1 Q2)
Member is receiving non‑surgical cancer treatment (radiation, chemotherapy) (Section 1 Q3) — provide date of last treatment
Member is receiving surgical cancer treatment (Section 1 Q4) — provide date of last surgery

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyContinuity of Care request process

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionMember completes Sections 1 and 2 and the treating provider completes and signs Section 3 before submitting the form for BCBSND review.

SourceLink

On This Page

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Member is receiving active treatment for HIV/AIDS (Section 1 Q5) — provide date of last treatment

Member is receiving active treatment for severe or end‑stage kidney disease or dialysis (Section 1 Q6) — provide date of last treatment

Member has recent bone marrow or organ transplant or is on waiting list (Section 1 Q7) — provide date of last treatment

Member is currently receiving inpatient services (Section 1 Q8) — provide facility name and date of admission

Member is receiving outpatient or inpatient mental health or substance use services by a licensed provider (Section 1 Q9) — 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 (Section 1 Q10) — provide provider name, date last seen and detailed description of condition

ALL of the following

Provider must provide: Provider Name, NPI, phone, fax, address, Date of Last Visit, Date of Next Scheduled Appointment, Frequency of Visits, Diagnosis, Expected Length of Treatment, Facility Name, Current and Planned Treatment/Comments
If maternity, provider must include expected date of delivery

ALL of the following

Ensure entire form is completed and signed by member and treating provider before submission
Submit completed form to BCBSND via mail or fax for review; BCBSND will approve or deny the Request for Continuity of Care

ALL of the following

If eligible, services may be continued at the participating in‑network benefit level for a specified duration determined by the eligibility event and expected length of treatment provided by the provider

ALL of the following

If member answered NO to all Section 1 questions, provider does not need to complete Section 3 and the continuity request is not applicable

Coding and Benefit Level

Not specifiedmixed

Duration / benefit level

Benefit levelServices are provided for a specific duration of time at the benefit level associated with participating, in-network providers.

Determination of durationDuration is determined per eligibility events listed in Section 1 of the form.

Eligibility linkageContinuity of Care eligibility is based upon the events listed in Section 1 of the form.

Review outcomeBCBSND will review the submitted information and notify the member of approval or denial.

Request and Provider Documentation Requirements

Prior Authorization

Complete Sections 1–3 and sign before submitting; mail or fax the form to BCBSND

Member must complete Section 1 and, if eligible, complete Section 2. The treating provider must complete Section 3 and sign the form before submission. Mail or fax the fully completed and signed form to BCBSND for review; BCBSND will notify the member of approval or denial.

Member: complete Section 1 and, if you answered YES to any question in Section 1, complete Section 2 and sign the form. [[DO NOT include chunk references in body]]
Provider: complete all of Section 3 (provider name, NPI, contact info, dates of visits, diagnosis, expected length of treatment, expected delivery date if maternity, current and planned treatment) and sign before submission.
Submit the fully completed form 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 by fax to (701) 277-2253.
BCBSND will review the submitted information and notify the member of the decision to approve or deny the Request for Continuity of Care.

Key Definitions

Continuity of Care — definition

DefinitionContinuity of Care allows BCBSND members to continue receiving covered health care services for specific medical conditions from a non-participating or out-of-network provider.

In-network benefit levelThese services are provided at the benefit level associated with participating, in-network providers for a specified duration.

Eligibility basisEligibility is based upon the events listed in Section 1 of the form; member and provider must complete and sign the form prior to submission.

Provider involvementMembers should ask their provider to complete Section 3; both member and provider signatures are required before submission.