CurrentHealth NetPolicy FRM1643301VCOlw

Continuity of Care Request Form and Process

This document explains Health Net's Continuity of Care (CoC) request form, how members and providers submit requests, what is reviewed, and available language/accessibility and grievance resources. It affects Health Net members and their providers seeking continued care from an out-of-network or transitioning provider.

Policy Summary

PayerHealth Net

PolicyContinuity of Care Request Form and Process

Policy CodePolicy FRM1643301VCOlw

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the Health Net Continuity of Care Request Form with patient, provider, and requested services information; send via fax to 1-866-295-4780 or by mail to Health Net Continuity of Care Dept., PO Box 9103, Van Nuys, CA 91409-9103.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-295-4780CoC submission fax number

PO Box 9103CoC mailing address

1-800-675-6110Member help

855-577-8234Grievance phone

benefits & medical needConsidered criteria

Continuity of Care Evaluation Criteria

Continuity of Care evaluation criteria

Requests for Continuity of Care are evaluated on enrollment benefits and clinical need. Examples of clinical situations included on the form:

ALL of the following

Examples of clinical situations
- Surgical procedure or procedure scheduled per appointment (Thu thuat/phau thuat theo lich hen)
- Newborn care from birth through 36 months (Cham soc tre so sinh tu khi moi sinh den 36 thang)
- Acute care condition (Tinh trang cap tinh)
- Serious chronic condition (Tinh trang man tinh nghiem trong)

Policy Summary

PayerHealth Net

PolicyContinuity of Care Request Form and Process

Policy CodePolicy FRM1643301VCOlw

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Submission, Review, and Required Documentation

Prior Authorization

Submission instructions for Continuity of Care requests

Submit a completed Health Net Continuity of Care Request Form (Phieu Yeu Cau Cham Soc Lien Tuc). Provide full provider and patient information and indicate the request type (urgent or standard). Fax the completed form to 1-866-295-4780 or mail to Health Net Continuity of Care Dept., P.O. Box 9103, Van Nuys, CA 91409-9103. Include the treating provider's name, address, phone, tax ID (if available), diagnosis, CPT codes, next scheduled appointment date, and reason for the appointment.

Form must be fully completed and signed by the patient or authorized representative.
Indicate request urgency: Urgent or Standard.
Fax submissions: 1-866-295-4780.
Mailing address: Health Net Continuity of Care Dept., P.O. Box 9103, Van Nuys, CA 91409-9103.

Note

Review process and decision factors

After Health Net receives the completed Continuity of Care Request Form, we will assign a clinical reviewer to evaluate the request. The decision will be communicated to the member by phone and/or mail once the form is complete. Each request is reviewed based on plan benefits, applicable state and federal regulations, clinical appropriateness, and the member's clinical need.

Decision factors: member's benefit plan coverage and eligibility.
Decision factors: applicable state and federal continuity-of-care regulations.
Decision factors: clinical appropriateness and the clinical reviewer’s assessment of medical necessity.
Decision factors: documented clinical need and scheduled appointments.

Documentation Required

Required clinical documentation on form

Required clinical documentation to accompany the Continuity of Care Request Form. Attach copies or provide the information directly on the form to support the request.

Treating provider name, address, phone number, and tax ID (if available).
Primary diagnosis and relevant clinical history.
Relevant CPT/procedure codes and dates of service.
Date of next scheduled appointment and reason for the appointment.
Documentation that the patient was seen by the provider at least once in the past 12 months, if applicable.
Signature of the patient or authorized representative.

OpenPayer

Continuity of Care Request Form and Process

Continuity of Care Evaluation Criteria

Requested Services and Coding Details

Submission, Review, and Required Documentation

Forms and Definitions