ModifiedUnitedHealthcarePolicy BIP023.Q

Continuity of Care

This document defines UnitedHealthcare's Continuity of Care benefit interpretation, describing when members may continue care with terminated or out-of-network providers and referencing applicable federal and California state continuity statutes. It applies to UnitedHealthcare members and contracting providers in the jurisdictions covered by the document.

Policy Summary

PayerUnitedHealthcare

PolicyContinuity of Care

Policy CodePolicy BIP023.Q

Change TypeAdded No Surprises Act languagerevised CA HSC 1373.96

Effective DateFeb 1, 2026

Next Review Date

Key ActionSubmit requests for continuity of care from a terminated provider to UnitedHealthcare within 30 calendar days of provider termination for review and approval.

SourceLink

POLICY UPDATE CHANGES

Added language pertaining to the No Surprises Act, Requirements Related to Surprise Billing, Part I.

Revised language pertaining to the California Health and Safety Code (HSC) Section 1373.96.

Archived previous policy version BIP023.P.

6CA statutory condition types listed

60 daysReplacement coverage timeframe

12 monthsMax continuity period (several conditions)

30 daysRequest timeframe after termination

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Inpatient continuation limit

36 monthsNewborn care age limit

Continuity of Care Coverage Criteria

Continuity of Care coverage criteria

Continuity of care may be covered when statutory criteria are met for newly enrolled members, existing members with terminated providers, and members transitioning between plans. Coverage is limited to specified conditions and timeframes per statute.

ANY of the following

Member is a newly enrolled member receiving services from an out-of-network provider
See requirements for newly enrolled members and condition types
Member is an existing member receiving care from a terminated provider
See terminated provider requirements; continuity requests must meet operational conditions
Member is an existing member transitioning from one plan to another with a provider that is not in-network
Member may apply for continuity during plan transition per member materials

Plan responsibility: UnitedHealthcare becomes responsible for covered services as of the member's first date of eligibility; continuity may apply in the circumstances above

Operational responsibilities and member materials described in EOC/SOB

Continuation is limited to covered services and to the continuity of care conditions and durations defined by statute (see condition-specific limits)

Cost sharing follows plan terms; plan may require provider agreement to contract terms and payment rates

Eligibility and General Conditions

Continuity of care may be covered when criteria are met for new enrollees receiving care from out-of-network providers, members receiving care from terminated providers, or members transitioning plans with an out-of-network provider.

ANY of the following

Newly enrolled member who was receiving covered services from an out-of-network provider at the time the member's coverage became effective
Services must be for one of the statutory continuity conditions
Existing member receiving care from a provider whose contract with the plan has terminated
Member must submit request and provider must meet terminated-provider requirements
Existing member transitioning between plans who is receiving services from a provider who is not in-network with the new plan
Members may apply for continuity per EOC/SOB instructions

Requested treatment must be a covered health care service under the member's plan

Terminated Provider Requirements

Conditions specific to continuation with a terminated provider.

A request for continuity of care services from a terminated provider must be submitted to UnitedHealthcare within 30 calendar days from the date the provider is terminated for review and approval

Timely submission required for consideration

The requested treatment must be a covered health care service under the member's health plan

Continuation cannot be approved for non-covered services

The terminated provider must agree in writing to be subject to the same contractual terms and conditions that were imposed prior to termination (credentialing, privileging, utilization review, peer review, quality assurance, etc.)

If the provider does not agree or comply, the plan is not required to continue the provider's services beyond the contract termination date

The terminated provider must agree in writing to compensation at rates and methods similar to those used by UnitedHealthcare or the provider group for current network providers providing similar services in the same or similar geographic area

Continuity of Care Condition Types and Limits

Defined continuity of care conditions with duration limits and special rules.

ONE of the following condition types must apply

Acute condition: sudden-onset medical or mental health condition requiring prompt attention; completion of services provided for the duration of the acute condition
See definition for scope and duration
Serious chronic condition: serious, persistent condition requiring ongoing treatment; continuation provided to complete active treatment and arrange safe transfer, not to exceed 12 months from contract termination or from newly enrolled member's effective date
Completion period determined in consultation with UnitedHealthcare medical director and provider(s)
Pregnancy: coverage through the three trimesters and immediate postpartum period; maternal mental health condition: continuation up to 12 months from diagnosis or from end of pregnancy, whichever is later
Member must provide written documentation for maternal mental health diagnosis when applicable

Not Covered / Exclusions

Exclusions and general non-covered services.

Continuity of care is only provided as described in the Federal/State mandated regulations, state market plan enhancements, and covered benefits sections; services outside those provisions are not covered

Policy examples are illustrative, not exhaustive

Examples of not covered services include

Routine exams, vaccinations, and health assessments
Chronic conditions that are stable (except as otherwise required by state law)
Minor illnesses such as colds, sore throats, and ear infections

Continuity does not apply when the provider was terminated for disciplinary reasons, fraud, or criminal activity

Coding and Duration Key Values

Referenced legacy diagnosis codes for congenital anomaliesICD-10

ICD-9-CM 749	Cleft lip and palate (referenced for congenital craniofacial anomalies protection)
ICD-9-CM 755.55	Acrocephalosyndactyly (cranio only) referenced
ICD-9-CM 756.0	Other congenital musculoskeletal anomalies referenced

N/Amixed

No codes listed

inv-08: Maximum continuity duration — general 12-month guidance and exceptions

General maximum durationGenerally 12 months from the contract termination date or from the member's effective date of coverage for newly enrolled members for specified conditions

Terminal illness exceptionCompletion of covered services for a terminal illness may exceed 12 months and continues for the duration of the terminal illness

Newborn limit linkageNewborn care completion shall not exceed 12 months from termination/effective date and shall not extend beyond the child's third birthday

Provider agreement requirementPlan may require terminated or nonparticipating providers to agree in writing to contractual terms as a condition of continuation

inv-09: Condition-specific duration limits — varies by condition (acute, chronic, pregnancy, newborn, inpatient limits, etc.)

Provider and Member Action Requirements

Note

Plan responsibility and continuity circumstances

In accordance with California Health and Safety Code (HSC) Section 1373.96 and UnitedHealthcare policy, the member’s new carrier becomes responsible for all health care services as of the member’s first date of eligibility with the plan. The Medical Group/IPA and capitated hospital become responsible to authorize and direct a member’s care and pay claims as of the member’s first date of eligibility with the new health plan, regardless of the member’s inpatient status. These requirements do not apply when a new member was offered an out‑of‑network option or had the option to continue with the previous health plan or provider and voluntarily chose to change plans.

Prior Authorization

Request submission for terminated providers

A request for continuity of care services from a terminated provider must be submitted to UnitedHealthcare within 30 calendar days from the date the provider is terminated for review and approval. Requests received after 30 calendar days may be denied unless other statutory or plan continuation provisions apply.

Submit COC request within 30 calendar days from provider termination date
Timely submission required for review and approval

Definitions

inv-13: Maternal mental health condition — definition and scope

DefinitionA maternal mental health condition is a mental health condition that can impact a woman during pregnancy, peri- or postpartum, or that arises during pregnancy, in the peri- or postpartum period, up to one year after delivery

Documentation requiredMember's current provider must provide written documentation of the maternal mental health condition diagnosis from the treating health care provider

Duration for continuityCompletion of covered services for maternal mental health shall not exceed 12 months from diagnosis or from the end of pregnancy, whichever occurs later

inv-14: Nonparticipating provider — definition

DefinitionA nonparticipating provider is a provider who is not contracted with the enrollee's health care service plan to provide services under the enrollee's plan contract

Plan requirements

Policy Summary

PayerUnitedHealthcare

PolicyContinuity of Care

Policy CodePolicy BIP023.Q

Change TypeAdded No Surprises Act languagerevised CA HSC 1373.96

Effective DateFeb 1, 2026

Next Review Date

Key ActionSubmit requests for continuity of care from a terminated provider to UnitedHealthcare within 30 calendar days of provider termination for review and approval.

SourceLink

On This Page

Continuation does not require coverage of services not otherwise covered

Continuation requests are subject to review for medical necessity and appropriateness by UnitedHealthcare (including review by a medical director as applicable)

Safe transfer determinations made in consultation with member and provider(s)

Plan need not continue services if provider will not accept payment rates

Member's continuation will end when the condition is medically stable and there are no clinical contraindications to a safe transfer to a network provider, as determined by a UnitedHealthcare medical director in consultation with the member and provider(s)

Completion determined clinically

Terminal illness: continuation provided for the duration of the terminal illness (may exceed 12 months)

Terminal illness defined as condition with high probability of death within one year; statutory exception to 12-month cap

Care of a newborn: services from birth to age 36 months; completion of services will not exceed 12 months from provider termination or newly enrolled member effective date and will not extend beyond the child's third birthday

Applies to newborn up to 36 months

Authorized surgery or other procedure: performance of surgery or other procedure authorized by UnitedHealthcare or the member's assigned network provider as part of a documented course of treatment and recommended to occur within 180 days of contract termination or newly enrolled member effective date; includes postoperative care

Surgery/procedure must be scheduled within 180 days to qualify

Inpatient or institutional care: unless otherwise specified, continuity continues until the earlier of 90 days from notice of right to continuation or the date the member is no longer a continued care patient with respect to that provider or facility

90-day limit for inpatient/institutional care unless other condition-specific rules apply

Provider-termination-for-cause exclusions prevent continuation

Continuation will not be approved for care that would exceed 12 months beyond the provider's termination date or the member's effective date of coverage, except for terminal illness where the 12-month limit does not apply

Statutory duration limits apply

Acute conditionsCompletion of covered services provided for the duration of the acute condition (sudden onset, limited duration)

Serious chronic conditionsCompletion of services for the period needed to complete active treatment and arrange safe transfer, not to exceed 12 months from termination or effective date

Pregnancy and maternal mental healthPregnancy: covered through the three trimesters and immediate postpartum; Maternal mental health: up to 12 months from diagnosis or end of pregnancy, whichever is later

Terminal illnessCovered for the duration of the terminal illness; may exceed 12 months

Newborn careServices from birth to 36 months; completion not to exceed 12 months from termination/effective date and not beyond the child's third birthday

Authorized surgery/procedureIf surgery/procedure is authorized as part of a documented course of treatment and is scheduled within 180 days of termination or effective date, continuation includes peri/postoperative care

Inpatient/institutional careUnless specified otherwise, continuity continues until the earlier of 90 days from notice of right to continuation or when member is no longer a continued care patient

Note

Member application for COC during plan transition

Members transitioning from one plan to another who are receiving care from a provider that is not in‑network may apply for Continuity of Care (COC). Members should follow the COC application instructions in their Evidence of Coverage (EOC)/Schedule of Benefits (SOB). COC may be approved when the care is medically necessary, the treatment is a covered benefit under the member’s plan, and there are no clinical contraindications to transfer as determined by a UnitedHealthcare medical director in consultation with the member and providers. If a terminated provider is involved, the provider must agree in writing to applicable contractual terms and to compensation at rates and methods similar to current network providers in the same geographic area.

Member must apply for COC following instructions in the member's EOC/SOB
COC approval requires care to be medically necessary and a covered service under the member’s plan
For terminated providers, written agreement to contractual terms and comparable compensation is required

Plan may require a nonparticipating provider whose services are continued for a newly covered enrollee to agree in writing to contractual terms and conditions

Effect of refusalIf the nonparticipating provider does not agree or comply, the plan is not required to continue the provider's services

inv-15: Individual provider — definition referencing licensure

DefinitionAn individual provider means a person who is a licentiate as defined in Section 805 of the Business and Professions Code, or a person licensed under Chapter 2 of Division 2 of the Business and Professions Code

ScopeIncludes persons licensed to provide medical or mental health services as specified by state licensing statutes

inv-16: Acute Condition — definition and implications for continuity

DefinitionAn Acute Condition is a medical or mental health condition involving sudden onset of symptoms that requires prompt medical attention and has a limited duration

Continuity implicationCompletion of covered services will be provided for the duration of the acute condition

Reference for benefitsMembers should refer to their Evidence of Coverage for specific benefit limits and behavioral health supplements where applicable

inv-17: Serious Chronic Condition — definition and continuity period rationale

DefinitionA Serious Chronic Condition is a serious, persistent medical or mental health condition that persists without full cure or worsens over time and requires ongoing treatment to maintain remission or prevent deterioration

Continuity period rationaleCompletion of covered services is provided to complete active treatment and arrange for a clinically safe transfer; continuity for these conditions will not exceed 12 months from termination or effective date

Decision authorityDuration and safe transfer arrangements are determined by the health care service plan in consultation with the enrollee and the terminated or out-of-network provider, consistent with good professional practice

inv-18: Pregnancy / Maternal Mental Health — definition covering pregnancy, peri/postpartum, and related conditions

DefinitionPregnancy includes the three trimesters and the immediate postpartum period; maternal mental health conditions arise during pregnancy or up to one year after delivery

Coverage durationCompletion of covered services for pregnancy is provided for the duration of the pregnancy; for maternal mental health, coverage not to exceed 12 months from diagnosis or end of pregnancy

Transfer planningUnitedHealthcare will consult with the member and the terminated or out-of-network provider to arrange a safe transfer consistent with good medical practice

inv-19: Terminal Illness — definition and continuity considerations

DefinitionTerminal Illness is an incurable or irreversible condition that has a high probability of causing death within one year or less

Continuity considerationCompletion of covered services will be provided for the duration of the terminal illness and may exceed 12 months from the termination or effective date

Clinical determinationDuration and ongoing need are determined in consultation with the plan and treating provider consistent with good professional practice

inv-20: Newborn Care — definition and age limit (birth to 36 months)

DefinitionNewborn care refers to services provided to a child from birth up to age 36 months (third birthday)

Age limitCompletion of covered services shall not exceed 12 months from the provider agreement termination date or the newly enrolled member's effective date, and shall not extend beyond the child's third birthday

ApplicabilityApplies to continuity of care for newborns when statutory criteria are met for continuation with terminated or nonparticipating providers