CurrentPresbyterian Health PlanPolicy N/A

Transition of Care Services Request Form

Form and instructions to request Transition of Care services for members of Presbyterian Health Plan, including eligibility reasons, required provider and service information, and submission instructions. Affects members, dependents, providers, and plan enrollment staff.

Policy Summary

PayerPresbyterian Health Plan

PolicyTransition of Care Services Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrior Authorization is required for out-of-network services rendered by an out-of-network provider during the 90-day transition period and is subject to approval by a Presbyterian Health Plan medical director.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystransition of care period from effective date

90 daystransition of care period following provider contract termination

Faxsubmission method and number

Language helpnondiscrimination and interpreter contact

Transition of Care Eligibility and Requirements

Transition of Care eligibility and requirements

Transition of Care may be approved for specified circumstances and may require prior authorization for out-of-network providers.

ALL of the following

Eligible circumstances (one or more must apply)
- Member needs a transplant and is scheduled for one or has just had one.
- Member has a scheduled upcoming surgical procedure.
- Member had a surgical procedure and is undergoing follow-up care.
- Member has a serious medical condition that requires ongoing care.

Policy Summary

PayerPresbyterian Health Plan

PolicyTransition of Care Services Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

Codes and Transition Period

Member-supplied clinical codesmixed

Diagnosis codes (from your provider)	Member/provider to supply relevant diagnosis codes
Procedure/CPT codes (from your provider)	Member/provider to supply relevant procedure/CPT codes

Transition period length

Transition period lengthApproximately 90 days from the member's effective date or for 90 days following a provider's contract termination

Prior authorization during periodPrior Authorization is required for out-of-network services rendered by an out-of-network provider during the 90-day transition period and is subject to approval by a Presbyterian Health Plan medical director.

Plan types with special payment treatmentFor POS and PPO members, out-of-network services approved for Transition of Care may be payable as in-network during the transition period.

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization required for out-of-network services during 90‑day Transition

Prior Authorization is required for out-of-network services rendered by an out-of-network provider during the 90-day transition period. Approval of the Prior Authorization is subject to review and approval by a Presbyterian Health Plan medical director.

This requirement applies during the ~90-day Transition of Care period from the member's effective date or for 90 days after a provider's contract termination.
For POS and PPO members, approved out-of-network Transition of Care services may be payable as in-network for the Transition period (where applicable).

Transition of Care Services Definition

Definition: Transition of Care services

Scope of Transition of Care servicesServices available for about 90 days from the member's effective date or for 90 days after a provider's contract termination.

Circumstances coveredIncludes situations such as scheduled surgery, post-operative follow-up, transplants (scheduled or recent), ongoing serious medical conditions, and pregnancy (remainder of pregnancy, delivery, plus postpartum care).

Out-of-network treatment and approvalPrior Authorization is required for out-of-network services by out-of-network providers during the transition period; approvals may allow in-network payment treatment for POS and PPO members.