will apply to all services performed on or after the above revision date which
will become the new effective date.
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
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.