Currentculinary health fundPolicy N/A

Continuity of Care Request Form

A member-facing form and instructions for requesting continuity of care when a provider is leaving the network; governs submission, eligibility circumstances, and notification for affected members.

Policy Summary

Payerculinary health fund

PolicyContinuity of Care Request Form

Policy CodePolicy N/A

Change TypeAdministrative/Operational update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate Continuity of Care Request Form within 30 days of notice and include the patient signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daystimeframe to apply from date of notice

8qualifying condition questions

1separate form required per condition

approval/denial/under reviewnotifications provided to member

Continuity of Care — Eligibility Criteria and Process

Continuity of Care criteria and process

Continuity of Care may be granted for the specified medical condition(s) listed on the request form when the member provides the required information and signs the form. Apply within 30 days of notice and submit a separate form for each condition.

Member submits a completed Continuity of Care Request Form with required member and provider information (member name, ID, contact, patient name/DOB, provider terminating, provider termination date) and member (or guardian) signature.

Qualifying medical conditions (ONE or more):

Pregnancy — indicate pregnancy, due date, and whether it is high-risk; provide description as requested.
Acute condition or trauma — indicate current treatment for an acute condition or trauma.
Scheduled surgery or hospitalization — indicate if surgery or hospitalization is scheduled with the terminating provider after the provider's termination date; if non-elective, include type and proposed surgery date.

Policy Summary

Payerculinary health fund

PolicyContinuity of Care Request Form

Policy CodePolicy N/A

Change TypeAdministrative/Operational update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate Continuity of Care Request Form within 30 days of notice and include the patient signature.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Cancer treatment or terminal care — indicate involvement in chemotherapy, radiation, cancer treatment, or terminal care with the terminating provider.

Post-major surgery follow-up — indicate ongoing treatment or follow-up care resulting from a recent major surgery.

Dialysis — indicate if the patient is currently receiving dialysis treatment.

Organ transplant candidacy — indicate if the patient is a candidate for organ transplant.

Other — describe the condition, when it began, frequency of visits, current or proposed treatment plan, and expected length of treatment.

For 'Other' conditions provide detailed information: state the health condition, onset, frequency of visits, be as specific as possible, include current or proposed treatment plan and expected treatment duration.

Use a separate Continuity of Care Request Form for each condition; photocopies and attached additional information are acceptable.

Member will be notified of the decision: approved, denied, or under medical review.

Approval applies only to the treatment of the condition(s) specified on the request form; all other conditions must be managed by an in-network provider to receive in-network coverage.

If continuing out-of-network care beyond approved period and the plan permits out-of-network coverage, member remains subject to out-of-network cost-sharing, pre-certification, and other SPD provisions.

Approval of Continuity of Care does not guarantee medical necessity and does not waive prior authorization or pre-certification requirements; services continue to be subject to the plan's medical necessity and prior authorization rules.

Provider and Plan Actions When Continuity is Requested

Prior Authorization

Continuity approval limits — approvals do not waive medical necessity or prior authorization

Approval of Continuity of Care is limited to the treatment of the specific medical condition(s) listed on the Continuity of Care Request Form and does not change other coverage rules. Services provided under an approved Continuity of Care request remain subject to the plan's medical necessity determinations and any required prior authorization or pre-certification rules in the member's Summary Plan Description.

Approval applies only to the condition(s) specified on the request form; other conditions require in-network care for in-network coverage.
Continuing care out-of-network beyond the approved period may subject the member to out-of-network cost-sharing, pre-certification, and other SPD provisions.
Approval does not guarantee medical necessity and does not waive prior authorization/pre-certification requirements.

Key Definitions

Continuity of Care Request Form — definition and brief descriptor of the member-submitted form

DefinitionContinuity of Care Request Form: a member-submitted form to request continued care with a provider who is terminating participation in the network.

UseSubmit to request continued treatment for a specific medical condition when the member’s provider is leaving the network; use a separate form for each condition.

Required patient informationMember and patient identifiers, provider terminating the member's network, provider office location, and provider termination date.

Qualifying condition questionsThe form asks about pregnancy (including due date and high-risk status), acute condition/trauma, scheduled surgery/hospitalization, cancer/terminal care, post-major surgery follow-up, dialysis, transplant candidacy, or an 'other' condition description.

AttachmentsPhotocopies and additional information may be attached as needed.