Medical Policy

Effective Date:09/08/2004	Title:Continuity of Care
Revision Date:09/01/2014	Document:BI069:00
CPT Code(s):
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. All services provided out of our network to provide for continuity of care require preauthorization. A care manager will make a determination about what services will be covered under this continuity of care provisions. When a member newly enrolled in a QualChoice plan is being treated by a nonparticipating provider for a current episode of an acute condition (as determined by QualChoice), the member may continue to receive treatment as an in-network benefit from that provider until the current episode of treatment ends or until the end of ninety (90) days, whichever occurs first. In the case that a member’s QualChoice network provider ceases to have a contract with QualChoice (no matter what the cause of the termination of the contract), the member should begin transfer of care to a new, in-network provider immediately upon notification. The member may continue to receive treatment as an in-network benefit from the previously contracted provider until the current episode of treatment ends or until the end of ninety (90) days, whichever occurs first. During a period during which continuity of care applies, our payment to the provider will apply our maximum allowable in-network fee schedule; in-network co-payments, co-insurance and deductibles will apply.
Medical Statement
Pregnancy and Prenatal Care: Any woman who is in her third trimester of pregnancy will not be required to change obstetrician. If the provider change is a hospital change, and the physician has privileges at both hospitals, the patient will be expected to deliver at the new participating hospital. Any woman who is earlier in her pregnancy than the third trimester will be expected to transition care to a participating obstetrician. Acute illness care: Any patient in the midst of a course of treatment for an acute (self-limited) illness, or of a defined and limited course of treatment for a chronic illness (such as radiation treatment for a cancer) will be allowed up to 90 days to change to a participating provider. The patient will be expected to arrange for care with a participating provider either by the end of the course of treatment or 90 days, whichever comes sooner. If the patient requires assistance in making the provider change, that assistance will be provided by QualChoice Care Management personnel. Chronic illness care: Care for chronic illnesses must be shifted to participating providers as soon as possible. Visits to the previous provider will only be authorized in extraordinary circumstances at the sole discretion of QualChoice.
Limits
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Reference
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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.