CurrentPremera BluecrossPolicy N/A

Continuity of Care - Administrative Policy

Describes Premera Blue Cross eligibility, application process, and timelines for continuing treatment with an out-of-network provider for covered services; affects members seeking to continue care when their provider leaves the network or is out-of-network.

Policy Summary

PayerPremera Bluecross

PolicyContinuity of Care - Administrative Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit a continuity of care request by phone to 800-344-2227 option 3 or fax the Out-of-Network Pre-Authorization and Exception Request Form to 800-843-1114.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysmaximum approved continuation period

10 business daysdecision timeframe for requests

8qualifying situations listed

Continuity of Care — Eligibility and Process

Continuity of care eligibility and process

Members may qualify for continuity of care if they meet ANY of the following qualifying situations. If approved, Premera will authorize continuation of treatment or care with the member's current out-of-network provider at in-network benefit levels for a limited period.

ONE of the following qualifying situations

Receiving treatment or care for pregnancy
Receiving care for short-term or acute illness or injury (for example: broken bone, strep throat, influenza, or COVID-19)
Receiving treatment or care for chemotherapy, radiation therapy, anticoagulation therapy, or a medication regimen requiring a rapid increase in dose
Receiving treatment for a long-term or chronic illness (for example: diabetes, asthma, or arthritis)

Policy Summary

PayerPremera Bluecross

PolicyContinuity of Care - Administrative Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must submit a continuity of care request by phone to 800-344-2227 option 3 or fax the Out-of-Network Pre-Authorization and Exception Request Form to 800-843-1114.

SourceLink

On This Page

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If member meets ANY qualifying situation above

Provider must submit a continuity of care request on the member's behalf by phone to 800-344-2227, option 3, or by fax using the Out-of-Network Pre-Authorization and Exception Request Form to 800-843-1114.
Care management team will review the request and make a decision within 10 business days (decision timeframe).
Decision timeframe: 10 business days
If approved, continuation of treatment or care is authorized for up to 90 days with the current out-of-network healthcare provider at the in-network benefit level, and may be limited to a defined period based on the treatment plan.
Maximum approved continuation period: up to 90 days

Decision Timeframes and Approved Duration

Decision timeframe — 10 business days

Decision timeframePremera care management team will make a decision on continuity of care requests within 10 business days.

Applies toRequests for continuation of treatment or care with a current out-of-network provider when member qualifies for continuity of care.

How measuredCountdown begins on receipt of the provider-submitted continuity of care request and ends when a decision is communicated (10 business days).

Approved continuation duration — up to 90 days

Maximum approved continuation periodIf approved, Premera will approve continued treatment or care for up to 90 days with the current out-of-network provider.

Benefit levelContinued care is provided at the in-network benefit level described in the member's benefit booklet for the approved period.

May be limitedContinuity of care benefits may also be limited to a defined period based on the treatment plan.

Key Terms

Continuity of care definition

DefinitionContinuation of care: continuing to receive treatment or care for specific covered services from a current provider.

ScopeApplies when a member may be able to continue specific covered services with their current (including out-of-network) provider under qualifying conditions.

Outcome if approvedApproved requests allow continuation of treatment or care with the current provider for a limited period at in-network benefit levels when applicable.

Qualifying situations — examples

PregnancyReceiving treatment or care for your pregnancy.

Short-term/acute illness or injuryReceiving care for short-term or acute illness or injury (e.g., broken bone, strep throat, influenza, COVID-19).

Chemotherapy, radiation, anticoagulation, or rapid-dose medication regimensReceiving treatment or care for chemotherapy, radiation therapy, anticoagulation therapy, or a medication regimen requiring a rapid increase in dose.

Long-term/chronic illnessReceiving treatment for a long-term or chronic illness such as diabetes, asthma, or arthritis.

Terminal illnessReceiving care for a terminal illness.

Recent major or reconstructive surgery follow-upReceiving care for a recent major surgery or follow-up of reconstructive surgery.

Mental health or substance use disorderReceiving treatment or care for mental health or substance use disorder.

OpenPayer

Continuity of Care - Administrative Policy

Continuity of Care — Eligibility and Process

Decision Timeframes and Approved Duration

How to Request Continuity of Care

Key Terms