CurrentCapital BluecrossPolicy N/A

Continuity of Care - Continued Care Request

Governs eligibility and administrative process for requesting up to 90 days of continued care from a provider whose network status has changed or for specific clinical situations; affects Capital Blue Cross members and treating providers in North Carolina where applicable and members covered under Capital Blue Cross plans.

Policy Summary

PayerCapital Bluecross

PolicyContinuity of Care - Continued Care Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit continuity of care request via fax to 717.346.6870 or by mailing completed form to Medical Management at Capital Blue Cross PO Box 773732 Harrisburg, PA 17177-3732.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 90 daysmaximum continued care period in many situations

90 daysfirst trimester allowance

remainder + 6w/90dsecond trimester allowance

remainder + 90dthird trimester allowance

faxsubmission method

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Continuity of Care — Criteria and Process

Continuity of Care Criteria and Process

Covered when ALL of the following apply:

ALL of the following

Eligible clinical situations (ONE or more):
- Ongoing course of treatment for a serious and complex condition (acute illness requiring specialized treatment to avoid death or permanent harm; chronic life‑threatening, degenerative, potentially disabling or congenital conditions; or chronic conditions requiring specialized prolonged care).
- A course of institutional or inpatient care.
- Scheduled for nonelective surgery (including post‑operative care).
- Receiving treatment for a pregnancy (see pregnancy‑specific allowances).
- Receiving treatment for a terminal illness.
Administrative and timing conditions:
- Request submitted and reviewed by Capital Blue Cross (requests are subject to review and approval).
- Situations affecting maximum continued care period:
  - General allowance: up to 90 days of continued care where applicable.
  - Provider network status change: provider agrees to provide care up to 90 days from the date the member received notice of the provider's change in network status.
  - Member newly effective on a Capital Blue Cross Medicare Advantage plan: eligible if within 90 days of their effective date and had a previously approved authorization from another health plan.

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Provider Responsibilities and Submission Instructions

Prior Authorization

Terms if continuity approved — provider obligations

If Capital Blue Cross approves continuity of care, the provider must continue to adhere to all Capital Blue Cross policies, procedures, and quality standards; accept Capital Blue Cross' network reimbursement rates (and any applicable member cost sharing) as payment in full and not balance bill the member for services during the approved continued care period; and provide copies of the member's medical records to Capital Blue Cross or the member's participating primary care provider prior to conclusion of the ongoing course of treatment.

Adhere to Capital Blue Cross policies, procedures, and quality standards for the member's services.
Accept network reimbursement rates and applicable member cost sharing as payment in full; do not balance bill the member.
Provide copies of the member's medical records to Capital Blue Cross or the member's participating PCP prior to conclusion of treatment.

Documentation Required

How to submit a continuity of care request

Key Definitions

serious and complex condition

DefinitionOngoing course of treatment for a serious and complex condition: an acute illness or condition requiring specialized medical treatment to avoid the reasonable possibility of death or permanent harm; a chronic illness that is life‑threatening, degenerative, potentially disabling, or congenital; or a chronic condition requiring specialized medical care over a prolonged period.

Acute illness exampleAn acute illness serious enough to require specialized treatment to avoid death or permanent harm.

Chronic life‑threatening / degenerativeA chronic illness or condition that is life‑threatening, degenerative, potentially disabling, or congenital.

Prolonged specialized careA chronic condition that requires specialized medical care over a prolonged period of time.

situations eligible for continued care

Institutional or inpatient care