CurrentPremera BluecrossPolicy N/A

Transition of Care for New Members with Out-of-Network Providers

Governs eligibility and process for new Premera Blue Cross members to continue specific covered treatments with an out-of-network provider temporarily; affects new members whose current provider is not in Premera's network.

Policy Summary

PayerPremera Bluecross

PolicyTransition of Care for New Members with Out-of-Network Providers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must fax a written request for transition of care on the member's behalf to 800-843-1114.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysdecision time for transition of care requests

7 clinical scenarioslisted qualifying situations

800-843-1114fax number for provider request

Transition of Care Eligibility and Criteria

Transition of Care Eligibility and Process

Members may qualify for transition of care if they are currently receiving care in any of the following situations. If approved, treatment may continue for a limited time at in‑network benefit levels; member may be responsible for charges that exceed the plan's maximum allowable amount.

ANY of the following

ALL of the following
- Receiving treatment or care for the second or third trimester of pregnancy
ALL of the following
- Currently enrolled in a hospice program
ALL of the following

Policy Summary

PayerPremera Bluecross

PolicyTransition of Care for New Members with Out-of-Network Providers

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must fax a written request for transition of care on the member's behalf to 800-843-1114.

SourceLink

On This Page

ALL of the following

Provider must fax a written request for transition of care on the member's behalf to 800-843-1114.
Provider must submit the request in writing via fax to the specified number.
Care management team will review the request and make a decision within five business days.
Decision timeframe begins on receipt of the provider's faxed written request.
If approved, member may continue treatment or care with the current out‑of‑network provider at the in‑network benefit level for a limited period; member may be responsible for charges that exceed the plan's maximum allowable amount and transition benefits may be time‑limited per the treatment plan.
Not all requests will be approved; approval is time‑limited and financial responsibility for amounts over plan maximums may apply.

Coding and Member Financial Responsibility

Inventorymixed

No codes listed

Maximum allowable payment exposure — member responsibilities and time limits

Member financial responsibilityMember may be responsible for charges that exceed the plan's maximum allowable amount.

Time-limited transition benefitsTransition of care benefits may be limited to a defined period based on the treatment plan.

In-network benefit level if approvedIf approved, continued treatment is paid at the in-network benefit level described in the member's benefits booklet.

Provider Submission & Review Timeline

Prior Authorization

Provider submission (fax request)

Provider must fax a written request for transition of care on the member's behalf to 800-843-1114.

Prior Authorization

Review timeline — decision within five business days

Our care management team will review the request submitted by your provider and make a decision within five business days.

Definitions

Transition of care — definition and process

DefinitionTransition of care allows a new member to continue treatment or care for specific covered services with their existing provider who is not in the Premera network; approved services are paid at the in-network benefit level.

Who may qualifyMembers currently receiving ongoing care (see eligibility criteria) such as late-term pregnancy, hospice, oncology treatments, recent major surgery, behavioral health/substance abuse, or scheduled surgery after enrollment.

How to applyProvider must fax a written request for transition of care on the member's behalf to 800-843-1114.

Decision timelineCare management will review the provider's request and make a decision within five business days.