CurrentCareSourcePolicy PASSE-AD-0992

Continuity of Care for Arkansas PASSE members

This administrative policy governs Continuity of Care (COC) processes for members of the Arkansas PASSE program, describing when and how CareSource provides temporary continuation of care during transitions between providers, plans, or following provider termination. It affects CareSource members, participating and non‑participating providers, and PASSE entities in Arkansas.

Policy Summary

PayerCareSource

PolicyContinuity of Care for Arkansas PASSE members

Policy CodePolicy PASSE-AD-0992

Change TypeEditorial updates and reference refresh

Effective Date01/01/2023-12/31/2023

Next Review Date

Key ActionRequests for Continuity of Care may be submitted by the member or a provider on the member's behalf and prior authorizations from another PASSE will be honored for up to 90 days or until a new PCSP is developed.

SourceLink

POLICY UPDATE CHANGES

Editorial changes and updated references were made on 09/28/2022; a note was added regarding nonmedical community support services.

90 daysminimum duration COC services will be provided when criteria met

06/09/2021original policy issue date

09/28/2022date revised

01/01/2023-12/31/2023policy effective period stated in header

Arkansasprogram/state targeted

Continuity of Care Coverage Criteria

Continuity of Care coverage criteria

COC services will be provided when members meet specified transition conditions or have ongoing/serious needs that would be disrupted by an immediate change:

ANY of the following

ALL of the following
- Member disenrolled from a PASSE for any reason other than ineligibility for Medicaid

ANY of the following

ALL of the following
- Provider terminated from the CareSource network

ANY of the following

Policy Summary

PayerCareSource

PolicyContinuity of Care for Arkansas PASSE members

Policy CodePolicy PASSE-AD-0992

Change TypeEditorial updates and reference refresh

Effective Date01/01/2023-12/31/2023

Next Review Date

SourceLink

On This Page

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ALL of the following

Member transitioning from fee-for-service (FFS) to a PASSE entity

ANY of the following

ALL of the following
- Member transitioning from one PASSE to another

Members with significant conditions or ongoing treatments: Members living in their own home who have significant conditions or treatments (examples include pain control, hypertension, enteral feedings, oxygen, wound care, ventilators)

Members receiving ongoing services such as intellectual and developmental disabilities services, serious mental illness services, in-home care, crisis behavioral health care, dialysis, home health, specialized pharmacy prescriptions, chemotherapy, radiation therapy

Members with prior authorizations: Members who have received prior authorization for services (examples include scheduled surgeries, post-surgical follow-up visits, therapies to be provided after transition, and out-of-area specialty services); prior authorizations will be honored for up to 90 days or until a new PCSP can be developed

Hospitalized at time of transition: Members who are hospitalized at the time of transition

Person-Centered Service Plan (PCSP): All members who have an existing PCSP will retain that care plan when enrolled into a new PASSE and care coordinators will update the PCSP as needed; continuation of care coordination and assignment to a local care coordinator will be provided to prevent disruption

Access to prior providers: Member may retain current provider for at least 90 days if that provider is not in the current network; member will be referred to appropriate in-network providers as needed

Duration and review: COC services will be provided for at least 90 days or until transition is completed, whichever is longer; COC services may be subject to medical necessity review

Requests, Authorizations, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Requests for Continuity of Care (COC) may be submitted by the member or by a provider acting on the member’s behalf. CareSource will accept and process COC requests for circumstances including provider termination from the network, member disenrollment from a PASSE for reasons other than Medicaid ineligibility, transitions from fee-for-service (FFS) to a PASSE entity, and transitions from one PASSE to another. COC services will be provided for at least 90 days when criteria are met and when, in the absence of services, the member would suffer serious detriment to health or be at risk of hospitalization or institutionalization. COC service requests and authorizations may be subject to medical necessity review.

Requests accepted from member or provider on behalf of member
COC applies when: provider terminated from CareSource network; member disenrolled from a PASSE for reasons other than Medicaid ineligibility; member transitions from FFS to a PASSE; member transitions from one PASSE to another
COC services provided for a minimum of 90 days or until transition is completed (whichever is longer)
COC services may be subject to medical necessity review

Continuity of Care and Related Terms

Continuity of Care and related terms

Acute conditionA medical or behavioral condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem requiring prompt medical attention with a limited duration.

Chronic conditionA medical or behavioral health condition due to a disease, illness, or other medical problem that is complex in nature and persists without cure, worsens over an extended period of time, or requires ongoing treatment to maintain remission or prevent deterioration.

Continuity of Care (COC)A process for assuring care is delivered seamlessly across multiple delivery sites and transitions in care throughout the course of the disease process; COC services will be provided for at least 90 days when policy criteria are met and may be subject to medical necessity review.

Non-Participating ProviderA provider who has not entered into a contractual arrangement with CareSource (also known as an out-of-network provider); members may retain a current provider for at least 90 days if that provider is not in the current network.

Person-Centered Service Plan (PCSP)A total plan of care for the member that includes services necessary for the member, any specific needs and strengths, and a crisis plan; existing PCSPs are retained when a member enrolls in a new PASSE and will be updated by care coordinators as needed.

Nonmedical Community Supports and Services (NCSS)Services provided to prevent or delay admission to an institutional setting or to assist with preparation for leaving an institutional setting; NCSS are not medical in nature, must be rooted in specific member needs identified through the Independent Assessment, and included in the PCSP.