Currentculinary health fundPolicy N/A

Continuity of Care Request Form

Form and process for members to request continuation of care with a provider who is terminating from the network; affects members seeking ongoing treatment with a departing provider.

Policy Summary

Payerculinary health fund

PolicyContinuity of Care Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete identifying information and termination date and obtain member signature authorizing release of medical records for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daystimeframe to apply for Continuity of Care after notice

separate form per conditionform requirement

notification of statusmember notification

limited to listed conditionscoverage limitation

Continuity of Care Coverage Criteria

Continuity of Care qualifying conditions and limits

Covered when the member meets ONE or more of the qualifying conditions related to ongoing treatment with a provider who is terminating from the network. Coverage is limited to the specific condition(s) listed on the request and remains subject to plan medical necessity and prior authorization rules.

Qualifying conditions (ONE or more)

Pregnancy (include due date and indicate if high-risk)
Acute condition or trauma currently receiving treatment
Scheduled surgery or hospitalization with the terminating provider occurring after the provider's scheduled termination (provide type and proposed surgery date if non-elective)
Current course of chemotherapy, radiation therapy, cancer treatment, or terminal care with the terminating provider

Policy Summary

Payerculinary health fund

PolicyContinuity of Care Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must complete identifying information and termination date and obtain member signature authorizing release of medical records for review.

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.

Coding and Medical Necessity

Not applicablemixed

No specific CPT/HCPCS/ICD-10/NDC codes referenced in this document.

Medical necessity / prior authorization requirements

RequirementServices provided under an approved Continuity of Care must meet the plan's medical necessity and prior authorization requirements as listed in the Summary Plan Description (SPD).

ScopeApproval of Continuity of Care does not itself guarantee medical necessity or waive pre‑certification requirements.

Reference for member responsibilityIf care continues out-of-network beyond the approved period, out-of-network cost-sharing, pre-certification, and other SPD provisions apply.

Provider Responsibilities and Billing Implications

Documentation Required

Form completion and medical record release

Provider must complete all identifying information on the Continuity of Care Request Form, including the member and patient details, provider office location, and the provider termination date. The signer (patient, parent, or guardian) attests to the information's validity and authorizes the physician or other health care professional to release the appropriate medical records to complete the review.

Use a separate form for each condition; photocopies acceptable
Attach supporting clinical information as needed
Ensure provider termination date is entered

Prior Authorization

Prior authorization and medical necessity

Services provided under an approved Continuity of Care arrangement remain subject to the plan's medical necessity review and any required prior authorization. Approval of Continuity of Care covers only the specified condition(s) and does not waive prior authorization or guarantee that services are medically necessary.

Continuity applies only to the condition(s) listed on the request form
All services must meet the plan's medical necessity criteria
Obtain prior authorization where required by the member's SPD before billing

Billing Rule

Out-of-network cost and billing implications

If a member continues care with an out-of-network provider beyond the approved Continuity of Care period, out-of-network cost-sharing, pre-certification, and other Summary Plan Description provisions apply. Providers should counsel members about potential billing and cost implications when continuity approval ends.

Out-of-network cost-sharing and billing rules will apply after the approved Continuity period
Pre-certification requirements in the SPD remain applicable
Inform members of potential higher member liability for out-of-network services

Definitions

Continuity of Care Request — definition

DefinitionA Continuity of Care Request is the form a member completes to request continuation of care with a provider who is terminating from the network; a separate form must be used for each condition.

Required detailsForm asks for member and patient identifying information, provider termination date, and condition-specific information (e.g., pregnancy status, acute condition, scheduled surgery, cancer treatment, recent major surgery, dialysis, transplant candidacy).

Supporting documentationQuestion 8 instructions request the condition description, onset date, frequency of visits, current/proposed treatment plan, expected treatment duration, and proposed surgery date if applicable.

Approved Continuity of Care — definition and limitations

DefinitionApproved Continuity of Care allows continuation of treatment only for the medical condition(s) specified on the request form; coverage is limited to those listed conditions.

LimitationsApproval does not guarantee that treatments are medically necessary and does not waive any pre‑certification requirements; services remain subject to SPD requirements.

Out-of-network implicationsIf member continues care out-of-network beyond the approved Continuity period, out-of-network cost-sharing, pre‑certification, and other SPD provisions will apply.