CurrentCapital BluecrossPolicy N/A

Request for Continuity of Care

Form and policy explaining eligibility, request, and terms for temporary continuation of care when a provider is leaving the Capital Blue Cross network or when a member transitions into a Capital Blue Cross plan; affects members and treating providers (including out-of-network) of Capital Blue Cross in Pennsylvania.

Policy Summary

PayerCapital Bluecross

PolicyRequest for Continuity of Care

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete Sections A and B of the form with member and provider information, treatment details, and signatures and submit to Medical Management via fax (717.346.6870) or mail to Capital Blue Cross.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystypical maximum transitional continuity period

remainder of pregnancy + 6 wks / 90 dayspregnancy continuity timing

Fully Insured, Exchange, MAmember types

717.346.6870fax to submit request

Continuity of Care Eligibility

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Continuity of Care Eligibility and Conditions

Members may be eligible for transitional continuity of care when receiving ongoing treatment for specific conditions or circumstances and when timely notice or plan transitions occur.

ALL of the following

ANY of the following
- Acute illness or condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.
- Chronic illness or condition that is life threatening, degenerative, potentially disabling, or congenital.
- Chronic illness or condition that requires specialized medical care over a prolonged period of time.
Course of institutional or inpatient care.
Scheduled for nonelective surgery (including post-operative care).
ALL of the following
- First trimester: eligible for 90 days of continued care following notice of provider termination.
- Second trimester: eligible for continued care through the remainder of the pregnancy, plus six weeks coverage after delivery OR 90 days coverage after delivery if delivery occurs during the second trimester.
- Third trimester: eligible for continued care through the remainder of the pregnancy, plus 90 days after delivery.
Receiving treatment for a terminal illness.

ONE of

Member is Fully Insured Commercial, Exchange, Managed Care, or Medicare Advantage and is in an ongoing course of treatment with an out-of-network provider: provider may agree to provide transitional care up to 90 days from the member's effective date with Capital Blue Cross.
Member is in an ongoing course of treatment and the provider's network status has changed: provider may agree to provide care up to 90 days from the date the member received notice of the change in network status.
Medicare Advantage member who is in an ongoing course of treatment, has a previously approved authorization from another health plan, and is within 90 days of their effective date with a Capital Blue Cross Medicare Advantage plan: eligible for up to 90 days transitional care.

ALL of the following

Provider must complete and submit the request form (Sections A and B) with member and provider information, treatment details, and required signatures via fax to 717.346.6870 or by mail to Medical Management, Capital Blue Cross.
Requests are subject to review and approval by Capital Blue Cross; if approved, the provider must adhere to Capital Blue Cross policies and quality standards, accept network reimbursement rates, and may not balance bill the member for services during the approved period of continued care.
Provider must provide copies of the member's medical records to Capital Blue Cross or the member's participating primary care provider prior to the conclusion of the ongoing course of treatment.

Form Submission, Approval, and Documentation Requirements

Prior Authorization

Complete Sections A and B and submit form

Complete Section A (member) and Section B (treating provider) of the Request for Continuity of Care form, providing member and employer details, patient identifiers, provider name and NPI, diagnosis/condition, treatment details (including length of time in treatment, number of visits, outline of treatment course, disposition), pregnancy status, provider termination date, and signatures. Submit the completed form by mail to Medical Management, Capital Blue Cross (PO Box 773732, Harrisburg, PA 17177-3732) or fax to 717.346.6870.

Section A must be completed by the member (subscriber name, employer, patient name, ID#, address, phone#, member notification date).
Section B must be completed by the treating provider (provider name, NPI#, address, phone#, provider termination date, diagnosis/condition, pregnancy status, procedures/services provided, length of time in treatment, # of visits, outline of treatment course, disposition).
Signed by provider and patient; submit by mail or fax to Medical Management (fax 717.346.6870).

Denial Risk

If approved, accept terms and network reimbursement

Requests are reviewed and approved by Capital Blue Cross; if continuity of care is approved, the provider must adhere to Capital Blue Cross' policies and quality standards, accept Capital Blue Cross' network reimbursement rates (and applicable member cost sharing) as payment in full, and must not balance bill the member for services during the approved period.

Provider must continue to adhere to all Capital Blue Cross policies, procedures, and quality standards.
Provider must accept Capital Blue Cross network reimbursement rates and any applicable member cost sharing as payment in full and may not balance bill the member.

Documentation Required

Provide member medical records before treatment ends

Prior to the conclusion of the ongoing course of treatment, the provider must provide copies of the member's medical records to Capital Blue Cross or to the member's participating primary care provider (or both).

Provide copies of the member's medical records to Capital Blue Cross and/or the member's participating PCP before treatment concludes.

Defined Terms Used in This Policy

Serious and complex condition

DefinitionOngoing course of treatment for a serious and complex condition

IncludesAcute life‑threatening conditions, chronic degenerative/disabling/congenital illnesses, conditions requiring specialized or prolonged care

Eligibility implicationMembers receiving such ongoing treatment may be eligible for continued care up to applicable transitional periods (e.g., 90 days)

Acute serious condition

DefinitionAn acute illness or condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm

ContextClassified as a reason a member may be eligible for continued care

ImplicationMay qualify the member for transitional continuity of care under this policy

Chronic serious condition

DefinitionA chronic illness or condition that is life threatening, degenerative, potentially disabling, congenital, or requiring specialized prolonged medical care

ExamplesConditions that are degenerative, disabling, congenital, or need prolonged specialized care (per policy language)

Eligibility implicationMembers receiving treatment for such chronic serious conditions may be eligible for continued care up to the stated transitional durations

OpenPayer

Request for Continuity of Care

Continuity of Care Eligibility

Coding and Continuity Duration

Form Submission, Approval, and Documentation Requirements

Defined Terms Used in This Policy