CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Transition of Care / Continuation of Care requests

Defines BlueCross BlueShield of South Carolina's transition/continuation of care benefits and the request/review process for members seeking temporary in-network level coverage when care is in progress or a provider is leaving the network.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyTransition of Care / Continuation of Care requests

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 17, 2016

Next Review DateN/A

Key ActionSubmit Transition of Care/Continuation of Care requests in writing via fax (803-264-0259), email (transitionofcare@bcbssc.com), or mail.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 business daystypical review timeline

803-264-0259fax

transitionofcare@bcbssc.comemail

in-networkapproved level

Coverage Criteria

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Approval and exclusion examples

Requests may be approved when treatment meets certain clinical circumstances; some conditions are explicitly noted as likely excluded.

ALL of the following

Examples of conditions that may meet criteria
- Member is undergoing a course of treatment for a serious and complex medical or behavioral health condition from a provider or facility.
- Member is currently undergoing a course of institutional or inpatient care from a provider or facility.
- Member is scheduled to undergo non-elective surgery from the provider.
- Member is pregnant and undergoing a course of treatment for the pregnancy from a provider or facility.
- Member is determined to be terminally ill with a life expectancy of 6 months or less.
Serious and complex condition definition
- Acute illness serious enough to require specialized medical or behavioral health treatment to avoid the reasonable possibility of death or permanent harm.
- Chronic illness or condition that is life-threatening, degenerative, potentially disabling, or congenital.
- Condition that requires specialized medical or behavioral health care over a prolonged period of time.
Likely exclusions (may not meet guidelines depending on circumstances)
- Routine examinations, vaccinations, testing, or health assessments.
- Stable chronic conditions (for example: diabetes, allergies, arthritis, asthma, hypertension, depression, anxiety, bipolar disorders).
- Minor illnesses (for example: colds, sore throats, ear infections, bronchitis, strains, sprains).
- Elective surgery or surgery scheduled for the member's convenience.
- Long-term management of conditions such as cancer, renal failure, dialysis, or transplants.

Coding and Approval Duration

not specifiedmixed

inv-03: approval duration

Approval durationRequests are approved for a specific period of time or a specific number of visits as determined by Managed Care Services review

Typical review timelineReview normally takes approximately 10 business days (expedited when possible)

Possible outcomesApproval for limited time/visits, denial, or request for additional information

Submission & Review Process (Provider Actions)

Prior Authorization

How to submit Transition/Continuation requests and review timeline

Submit all Transition of Care / Continuation of Care requests in writing via fax, email, or mail. Include a completed request form and a signed patient authorization for release of medical records (authorization expires six months from the date signed). Managed Care Services will review and notify the member in writing that the request is approved for a specific period or number of visits, denied, or that additional information is required. The review process normally takes approximately 10 business days. Mail submissions to BlueCross BlueShield of South Carolina, P.O. Box 100300, Columbia SC 29202, Attn: Transition of Care.

Fax: 803-264-0259
Email: transitionofcare@bcbssc.com
Mail: BlueCross BlueShield of South Carolina, P.O. Box 100300, Columbia SC 29202, Attn: Transition of Care
Patient authorization for release of medical records required; authorization expires six months from signature
Typical review timeline: approximately 10 business days
Possible review outcomes: approved for a specific period or number of visits; denied; or request for additional information

Definitions

inv-05: Transition of Care

DefinitionTransition of Care (treatment in progress): short-term benefit for new members being treated for an acute injury or illness by a non‑participating provider, allowing care at the in‑network benefit level for a limited time

Who it's forNew members whose treatment began with a provider who is not or is no longer in the network when coverage with BlueCross begins

LimitationsShort term only; does not replace regular policy provisions and members should work with their PCP or participating provider to arrange continued care

inv-06: Continuation of Care

DefinitionContinuation of Care: allows members to continue care with a network provider who is leaving the network at the in‑network benefit level, subject to medical management approval and time limits

Approval requirementContinuation of Care requires approval from medical management; if approved, benefits are provided for a limited amount of time

TimeframeMay be available for a limited time or until the member is no longer a Continuation of Care patient, whichever is shorter

Related processManaged Care Services reviews requests and will approve for a specific period/number of visits, deny, or request more information

inv-07: Serious and Complex Condition

DefinitionSerious and Complex Condition: an acute or chronic condition that is life‑threatening, degenerative, potentially disabling or congenital, or requires specialized medical or behavioral health care over a prolonged period

Examples - acuteAcute illness serious enough to require specialized treatment to avoid the reasonable possibility of death or permanent harm

Examples - chronicChronic illnesses that are life threatening, degenerative, potentially disabling or congenital

Treatment durationConditions requiring specialized care over a prolonged period may qualify for continuation of care for a limited time