Continuity of Care
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Governance of how Scripps Health Plan Services (SHPS/SHP) handles continuation of member services when a provider leaves the network, when new members are in active treatment with nonparticipating providers, or when benefits end but care is still needed; applies to SHPS Commercial and Scripps Health Plan lines noted in the document.
No material clinical or coverage changes in this revision.
Continuity of Care — Qualifying Conditions
Qualifying conditions and limits
Covered when ALL of the following qualifying conditions and operational limits are met:
Qualifying clinical conditions
- Acute condition: completion of covered services for the duration of the acute condition.
- Serious chronic condition: completion of covered services not to exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly enrolled member.
- Serious and complex medical condition: completion of covered services for the time necessary to complete a course of treatment and arrange a safe transfer, as determined in consultation with SHPS, member and provider; not to exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly enrolled member except as determined in consultation.
- Pregnancy: completion of covered services for the duration of the pregnancy.
- Maternal mental health condition: completion of covered services not to exceed 12 months from diagnosis or from the end of pregnancy, whichever occurs later.
- Newborn care (birth to age 36 months): completion of covered services not to exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered member.
- Authorized surgery/procedure (including postoperative care): when authorized by the plan as part of a documented course of treatment and recommended by the non‑contracting provider to occur within 180 days of the contract termination date or within 180 days of the effective date of coverage.
- Inpatient or institutional treatment: completion of covered services until the earlier of 90 days from the date the notice of the right to elect continuing care is provided or the date on which the member is no longer undergoing continuing care by that provider or facility.
- Terminal illness: completion of covered services for the duration of the terminal illness (may exceed 12 months).
Operational and administrative conditions
- Utilization Management will process continuity of care requests per SHPS procedures, review medical records, collaborate with physician reviewers and treating providers, and consider clinical effects and time needed for safe transfer.
- If UM agrees to continuation for a nonparticipating or terminated provider, the provider may be required to sign a written agreement to be subject to the same contractual terms and conditions (including credentialing, privileging, utilization review, peer review and quality assurance) and to accept payment rates and methods similar to those used for contracting providers or Medicare rates for senior members or an agreed upon rate; failure to agree relieves SHPS of the obligation to continue services.
- Cost sharing (copayments, deductibles, other cost‑sharing) during completion of covered services with a terminated or nonparticipating provider is the same as if the member were receiving care from a contracting provider.
- If a condition qualifies under more generous state or federal timeframes, the more generous timeframe applies.
- When benefits or benefit periods have ended, SHPS will assist with transition of care to another source of care or payment and refer members to Complex Care Management or other resources when needed.
Exclusions (not required to continue services)
- Provider termination for medical disciplinary cause, fraud, or other criminal activity.
- Services not covered under the terms and conditions of the plan contract.
- Newly covered member who was offered an out‑of‑network option or voluntarily changed plans instead of continuing with previous plan/provider.
Compensation & Duration Limits
| Payment rates to be similar to those used for contracting providers, Medicare rates for senior members, or agreed upon rate |
Request Processing, Agreements, and Coordination
UM processing and coordination on receipt of continuity request
Upon receipt of a continuity of care request, Utilization Management shall process the request as described in SHPS 800 Prospective Authorization Review; request prior health plans and/or providers to identify cases needing specialized coordination; review appropriate medical records in collaboration with the physician reviewer and treating provider; and determine continuation needs with consideration of clinical effects and time reasonably necessary for a safe transfer.
- Process request per SHPS 800 Prospective Authorization Review.
- Request previous health plans/providers to identify cases requiring specialized coordination and facilitate case review in advance of transition.
- Review medical records with physician reviewer and treating provider to determine continuation and duration, considering clinical effects and time needed for safe transfer.
Provider Relations letter of agreement and compensation conditions
If Utilization Management agrees to continuation of care with a nonparticipating provider, forward information to Provider Relations to complete a letter of agreement; continued services may require the provider to accept payment rates and terms similar to those used for contracting providers, Medicare rates for senior members, or an agreed upon rate, and failure to accept such rates relieves SHPS of the obligation to continue services.
- UM forwards approved continuation cases for nonparticipating providers to Provider Relations to complete a letter of agreement.
- Services rendered by terminated/nonparticipating providers shall be compensated at rates and methods similar to those used for contracting providers, Medicare rates for senior members, or an agreed upon rate; SHPS is not required to continue services if the provider does not accept these payment rates.
Key Definitions
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