POLICY STATEMENT:

Transition of Care (TOC) is a process of the BlueCross products that allows benefits for new members to continue care, with out-of-network specialists for a finite period of time.  A request for TOC requires review and approval through BlueCross Medical Management.

TOC is subject to contractual limitations and exclusions set forth in the member contract.  TOC does not extend the contractual benefits in any way except to provide network level of benefits for out-of-network providers for a defined time period.

Continuation of Care (COC) is a process of the BlueCross products that allows benefits for members to continue care with a network provider that is leaving the network.  COC requires approval from medical management and when the approval is obtained, COC allows network benefits for members for a finite period of time.

COC is subject to contractual limitations and exclusions set forth in the member contract.  COC does not extend the contractual benefits in any way except to provide network level of benefits for out-of-network providers for a defined time period.

To provide members residing in a network area on or before the provider expiration date with the opportunity to request COC consideration.  COC provides a method to ensure due diligence for continuity of care for members under active treatment for the acute phase of an illness, condition or injury.

Additionally, under South Carolina law, members may be eligible for in-network level benefit coverage for services rendered by physicians or performed in facilities that have withdrawn or been terminated from our plan's network.  This coverage is valid for up to 90 days or until the end of the current benefit period, whichever is longer.  This provision ensures continuity of care for serious medical conditions, where failure to provide the current course of treatment through the current provider would place the person's health in serious jeopardy.

PURPOSE:

To provide new BlueCross members residing in a network area, on or before the new effective date, with the opportunity to request TOC/COC consideration.  TOC/COC provides a method to facilitate a smooth transition of patient care to a network physician or provider, while ensuring continuity of care for members under active treatment or during current episode of care for the acute phase of an illness.

OBJECTIVES:

1. To determine the appropriateness of all TOC/COC requests
2. To evaluate the availability of network and non-network specialists
3. To obtain necessary approval for Transition of Care rendered by an out-of-network provider for a finite period of time
4. To obtain necessary approvals for continuation of care rendered by an out-of-network provider for a finite period of time

PROCEDURE:

1. TOC information will be included in the group enrollment packages.  TOC forms will also be made available to members through their employer benefits coordinator.
2. Prior to the contract effective date, the member will complete the TOC form and return it to the address listed on the TOC form.  The TOC form requires the minimum necessary information to complete this review.  TOC requests received after the effective date will be considered on a case-by-case basis.
3. Within 90 days of receipt of notification by Provider Contracting or National Alliance Partner Plans of a provider planning to terminate from the PPO network, the manager of utilization management will have a report generated to determine all members currently under treatment with the terminating provider.  A letter will be sent alerting the member of the planned termination and offering the continuation of care request form.
4. COC requests should be received from the member or subscriber via phone, fax or mail prior to the expiration date of the provider's network contract.  COC requests received after the expiration date will be considered on a case-by-case basis.
5. Requests for TOC/COC are received, imaged and logged by the area responsible for the new contract's medical management, and forwarded to the Medical Director and/or appropriate Medical Management staff for review.  The Utilization or Case Manager enters the TOC/COC on the TMCS system (See unit desk procedure on TOC/COC procedure).
6. Following the evaluation of the TOC/COC request, the Utilization/Case Manager will enter the determination of the TMCS system.
7. Decision Guidelines:

The following criteria will be used in the evaluation of the request for TOC/COC:

1. The Utilization/Case Manager will identify:For pregnant members who have been seen by their attending physician or obstetrician, or nurse midwife, the expected due date will be determined.  If the member is still within the first trimester of pregnancy or has not received any prenatal care, she must select a network obstetrician.  If the member is within the second or third trimester, and has received prenatal care, she will be given the opportunity to remain with her current obstetrician or transfer to a network obstetrician.  If she chooses to remain with her current obstetrician, a TOC/COC will be approved for network benefits.
   • if the member has an unstable or serious medical condition that requires a limited or finite course of treatment or follow-up care.  These conditions may include, but are not limited to:
     • pregnancy
     • recent acute heart attack
     • newly diagnosed cancer requiring surgery, chemotherapy, or radiation
     • physical therapy status post total joint replacement
     • acute trauma such as bone fracture
     • certain mental health treatment or substance abuse programs
   • The member's current attending physician and/or specialist and their network status.
   • Current plan of treatment and length of time being treated (current episode of care).
   • Verification of contract benefits for the services being rendered.
   • Verification that is not a chronic condition.  Examples of chronic medical conditions which are not likely to qualify for TOC include (see below)
     • arthritis-diabetes-hypertension-asthma-allergies
   • Avialability within the network for services being rendered.
2. For pregnant members who have been seen by their attending physician or obstetrician, or nurse midwife, the expected due date will be determined.  If the member is still within the first trimester of pregnancy or has not received any prenatal care, she must select a network obstetrician.  If the member is within the second or third trimester, and has received prenatal care, she will be given the opportunity to remain with her current obstetrician or transfer to a network obstetrician.  If she chooses to remain with her current obstetrician, a TOC/COC will be approved for network benefits.
3. If chemotherapy has been initiated, the member wil be permitted to continue with the current course of therapy which ends 90 days from the date that chemotherapy concludes.  Members in surveillance status would be covered at benefit level consistent with the network status of the provider.
4. If the member has a planned surgery scheduled within 30 days of transition date, the procedure wil be covered including 6-12 weeks of post-operative care.  Coverage beyond this time frame will be a benefit level consistent withn the network status of the provider.
5. Chronic condition care - One visit with provider within 30 days of transition date will be covered.  Care following that will be covered that will be covered at the benefit level consistent with the network status of the provider.
6. If the utilization/case manager cannot approve the TOC/COC, the request will be referred to the Medical Director for review (Refer to Medical Director Review Policy for instructions).

  8.  Claim payment during evaluation process:

1. Once a TOC/COC decision is made the determination will be entered into TMCS.  The claims department and the member will be notified of the decision in writing.
2. In-network level of benefits will be paid when the treatment or condition under consideration has been approved all other claims will be paid according to plan benefits.
3. When the treatment or condition under TOC/COC consideration has been denied:  Claims will be paid according to the plan for services received from an out of network provider.
4. If the approved TOC/COC provider is out of network, the member may be required to pay any amounts charged at or above the allowable rate.