CurrentCareSourcePolicy N/A

Continuity of Care - Arkansas PASSE

Governs CareSource's Continuity of Care procedures for Arkansas PASSE members, including transitional coverage when members change enrollment, providers, or PASSE entities, and who is eligible for continued services.

Policy Summary

PayerCareSource

PolicyContinuity of Care - Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review Date

Key ActionHonor prior authorizations from other payers for 90 days or until a new Person-Centered Service Plan (PCSP) is developed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysminimum period COC services will be provided or prior authorizations honored

30 daysadvance notice CareSource will make best efforts to give for practitioner/practice termination

20 business daystime for relinquishing PASSE to provide records and care files to receiving PASSE

60 daysperiod PASSEs coordinate services to ensure smooth transition/COC or until transition completed

Continuity of Care Coverage Criteria

Continuity of Care criteria

COC service requests are accepted from members or authorized representatives and will be provided for at least 90 days when the following criteria are met:

ALL of the following

ANY of the following
- Member or authorized representative may submit a COC request on the member's behalf.
Services will be provided for at least 90 calendar days when criteria are met.

Newly enrolled or transitioning members

Newly enrolled members, including those transitioning from Fee-For-Service to CareSource PASSE or between PASSE entities, may continue services with their current provider for at least 90 calendar days or until an appropriate in-network provider is found or the Person-Centered Service Plan (PCSP) is completed, whichever is longer.

Policy Summary

PayerCareSource

PolicyContinuity of Care - Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review Date

Key ActionHonor prior authorizations from other payers for 90 days or until a new Person-Centered Service Plan (PCSP) is developed.

SourceLink

On This Page

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Provider or facility termination scenarios

When a practitioner or practice group in general, family, pediatrics, or internal medicine leaves the network, CareSource will make best efforts to notify members at least 30 calendar days prior to the effective termination date and assist the member in selecting a new practitioner.30 calendar days notice (best efforts)
For termination of behavioral health or developmental disability services specialty providers, CareSource will make best efforts to notify affected members at least 30 calendar days prior to the effective termination date or within 15 days after receipt (whichever is later) and will assist the member in selecting a new specialty provider.

Priority populations and ongoing services

CareSource will address members living in private residences with significant conditions or treatments in a timely manner, including but not limited to pain control, hypertension management, enteral feedings, oxygen, wound care, ventilators, dialysis, chemotherapy or radiation therapy, and members hospitalized at time of transition.
CareSource will prioritize members receiving ongoing services such as Home and Community Based Services (HCB), intellectual and developmental disabilities services, services for serious mental illness or crisis behavioral health care, daily in‑home care, home health services or medical supplies, and specialized pharmacy prescriptions.

Provider Responsibilities and Prior Authorizations

Prior Authorization

Honor prior authorizations during transition

Prior authorizations obtained from the member's previous payer or relinquishing PASSE will be honored for 90 calendar days from the member's enrollment date or until a new Person-Centered Service Plan (PCSP) is completed, whichever occurs later. During this period, providers should continue to deliver authorized services consistent with the existing authorizations (for example, ongoing therapies, scheduled surgeries and related post‑surgical follow-up, and approved out-of-area specialty services) while CareSource and the receiving PASSE coordinate to establish a new PCSP and authorization set.

Honored duration: 90 calendar days from enrollment or until a new PCSP is developed, whichever is longer
Applies to: services previously authorized by another payer or relinquishing PASSE (including ongoing therapies, scheduled surgeries and post-surgical follow-up, and out-of-area specialty services)
Operational expectation: relinquishing PASSE must provide medical records, treatment plans, PCSP, and care coordination files timely (within 20 business days) and coordinate services for continuity of care for 60 calendar days or until transition completion
Notification expectation: when a practitioner or practice group leaves the network, CareSource will make best efforts to notify members at least 30 calendar days prior to termination
Exclusions: does not apply to providers terminated for reasons such as fraud or quality-of-care issues

Key Definitions

Acute Condition

DefinitionA medical condition, illness, or disease having a short and relatively severe course.

ContextUsed to identify conditions that may require immediate continuity of care during transitions.

ImplicationMay qualify a member for short-term COC protections when sudden onset risks service disruption.

Non-Participating Provider

DefinitionA provider who has not entered into a contractual arrangement with CareSource (out-of-network).

SynonymOut-of-network provider

RelevanceMembers may request continuity of care from non-participating providers under specified transition criteria.

Course of Treatment

DefinitionA prescribed order or ordered course of treatment for a specific individual with a specific condition that is outlined and decided upon ahead of time.

FormMay, but is not required to, be part of a broader treatment plan.

UseGuides decisions about honoring prior authorizations and continuity of services during transitions.

Participating Provider

DefinitionA provider who has agreed to provide services to covered persons with an expectation of receiving payment, directly or indirectly, from the healthcare insurer.

ExpectationIncludes payment beyond member cost-sharing (coinsurance, copayments, deductibles).

RoleParticipating providers are the in-network clinicians to whom CareSource directs members for ongoing care and transitions.

Serious and Complex Condition

DefinitionAcute: a condition serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; Chronic: a life‑threatening, degenerative, potentially disabling, or congenital condition requiring specialized medical care over a prolonged period.

ScopeCovers both acute illnesses requiring immediate specialized intervention and chronic conditions needing prolonged specialized care.

ImplicationMembers with serious and complex conditions are prioritized for timely coordination during transitions to prevent harm.

Person-Centered Service Plan (PCSP)

DefinitionA total plan of care for the member that includes necessary services, specific member needs, member strengths, and a crisis plan for the member.

ContentsIncludes services required, identified needs and strengths, and a crisis plan to guide continuity during transitions.

Use in COCExisting PCSPs will be honored and carried out until a new CareSource PCSP is created to avoid service disruption.