Continuity of Care. OMPP is committed to providing continuity of care for members as they transition between various IHCP programs and the Contractor’s enrollment. The Contractor shall have mechanisms in place to ensure the continuity of care and coordination of medically necessary health care services for its Hoosier Healthwise members. The State emphasizes several critically important areas where the Contractor shall address continuity of care. Critical continuity of care areas include, but are not limited to: Transitions for members receiving HIV, Hepatitis C and/or behavioral health services, especially for those members who have received prior authorization from their previous MCE or through fee-for-service; Transitions for members who are pregnant; A member’s transition into the Hoosier Healthwise program from traditional fee- for-service or HIP; A member’s transition between MCEs, particularly during an inpatient stay; A member’s transition between IHCP programs, Members exiting the Hoosier Healthwise program to receive excluded services; A member’s exiting the Hoosier Healthwise program to receive excluded services; A member’s transition to a new PMP; A member’s transition to private insurance or Marketplace coverage; and A member’s transition to no coverage. In situations such as a member or PMP disenrollment, the Contractor shall facilitate care coordination with other MCEs or other PMPs. When receiving members from another MCE or fee-for-service, the Contractor shall honor the previous care authorizations for a minimum of thirty (30) calendar days from the member’s date of enrollment with the Contractor. Contractor shall establish policies and procedures for identifying outstanding prior authorization decisions at the time of the member’s enrollment in their plan. For purposes of clarification, the date of member enrollment for purposes of the prior authorization time frames set forth in this section begin on the date the Contractor receives the member’s fully eligible file from the State. Additionally, when a member transitions to another source of coverage, the Contractor shall be responsible for providing the receiving entity with information on any current service authorizations, utilization data and other applicable clinical information such as disease management, case management or care management notes. This process shall be overseen by the Transition Coordination Manager. The Contractor will be responsible for care coordination after the m...
Continuity of Care. Provider shall cooperate with Subcontractor and Health Plan and provide a Covered Person with continuity of treatment, including coordination of care to the extent required under law, in the event Provider’s participation with Subcontractor terminates during the course of a Covered Person’s treatment by Provider.
Continuity of Care i. Ensure recovery-oriented services are connected to a range of continuing support services beyond a substance use treatment episode.
Continuity of Care. You may be able to continue to receive covered services from a provider for a limited period of time at the in- network benefit level after the provider ends his/her contract with Premera. To be eligible for continuity of care you must be covered under this plan, in an active treatment plan and receiving covered services from an in- network provider at the time the provider ends his/her contract with Premera. The treatment must be medically necessary and you and this provider agree that it is necessary for you to maintain continuity of care. We will not provide continuity of care if your provider: Will not accept the reimbursement rate applicable at the time the provider contract terminates Retired Died No longer holds an active license Relocates out of the service area Goes on sabbatical Is prevented from continuing to care for patients because of other circumstances Terminates the contractual relationship in accordance with provisions of contract relating to quality of care and exhausts his/her contractual appeal rights We will not provide continuity of care if you are no longer covered under this plan. We will notify you no later than 10 days after your provider’s Premera contract ends if we reasonably know that you are under an active treatment plan. If we learn that you are under an active treatment plan after your provider’s contract termination date, we will notify you no later than the 10th day after we become aware of this fact. You can call or send your request to receive continuity of care to Care Management at the address or fax number shown on the back cover.
Continuity of Care. CONTRACTOR shall follow the COUNTY’S continuity of care policy that is in accordance with applicable state and federal regulations, MHSUDS IN 18-059 and any BHINs issued by DHCS for parity in mental health and substance use disorder benefits subsequent to the effective date of this Agreement (42 C.F.R. § 438.62(b)(1)-(2).)
Continuity of Care. Continuity of care with a Non-Participating Provider may be available if your provider leaves the Blue Shield or MHSA networks, or if you are a newly-covered Member whose previous health plan was withdrawn from the market. You can request to continue treatment with your Non-Participating Provider in the situations described above if you are currently receiving the following care: • Ongoing treatment for an acute or serious chronic condition; • Pregnancy care, including care immediately after giving birth; • Treatment for a maternal mental health condition; • Treatment for a terminal illness; • Other services authorized by a now-terminated provider as part of a documented course of treatment; or • Care for a child up to 36 months old. To request continuity of care, visit xxxxxxxxxxxx.xxx and fill out the Continuity of Care Application. Blue Shield will confirm your eligibility and review your request for Medical Necessity. The Non-Participating Provider must agree to accept Blue Shield’s Allowable Amount as payment in full for your ongoing care. If the provider agrees and your request is authorized, you may continue to see the Non-Participating Provider at the Participating Provider Cost Share for: • Up to 12 months; • For a maternal mental health condition, 12 months after the condition’s diagnosis or 12 months after the end of the pregnancy, whichever is later; or • If you have a terminal illness, for the duration of the terminal illness. See the Your payment information section for more information about the Allowable Amount. Second medical opinion You can consult a Participating or Non-Participating Provider for a second medical opinion in situations including but not limited to: • You have questions about the reasonableness or necessity of the treatment plan; • There are different treatment options for your medical condition; • Your diagnosis is unclear; • Your condition has not improved after completing the prescribed course of treatment; • You need additional information before deciding on a treatment plan; or • You have questions about your diagnosis or treatment plan. You do not need prior authorization from Blue Shield or your PCP for a second medical opinion.
Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing a course of treatment for a serious and complex condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in the Complaint and Appeal Procedures section of this Certificate.
Continuity of Care. The parties shall co-operate to ensure continuity of care for patients during any transitory period relating to this Agreement, whether caused by the implementation or termination of this Agreement, or otherwise.
Continuity of Care. The State is committed to providing continuity of care for members as they transition between various IHCP programs and the Contractor’s enrollment. The Contractor shall have mechanisms in place to ensure the continuity of care and coordination of medically necessary health care services for its HIP members. The State emphasizes several critically important areas where the Contractor shall address continuity of care. Critical continuity of care areas include, but are not limited to: Transitions for members receiving HIV, Hepatitis C and/or behavioral health services, especially for those members who have received prior authorization from their previous MCE or through fee-for-service;
Continuity of Care. New Members may continue an on-going course of treatment with a Non-Participating Provider for a transitional period of up to ninety (90) days from the effective date of their Keystone coverage when approved by Keystone in advance of receiving services. Keystone, in consultation with the Member and the health care Provider, may extend this transitional period if determined to be clinically appropriate. If the new Member is in the second or third trimester of pregnancy, the transitional period will be extended to postpartum care related to the delivery. Members wishing to receive continuing care from a Non-Participating Provider for a transitional period must obtain Preauthorization for the requested services from Keystone. All terms and conditions of this Agreement, including Preauthorization requirements, will apply during any transitional period. Additionally, the Non-Participating Provider must agree to accept Keystone’s reimbursement as payment in full. Except in the case where a Participating Provider has been terminated for cause, if Keystone initiates termination of the contract with the Provider or a Participating Provider initiates termination with Keystone, the Member may continue an ongoing course of treatment with the Provider, at the Member’s option, for a transitional period of up to ninety (90) days from the date of the Participating Provider’s termination. Keystone, in consultation with the Member and the health care Provider, may extend the transitional period if determined to be clinically appropriate. In the case of a Member in the second or third trimester of pregnancy on the effective date of enrollment, the transitional period shall extend through the postpartum care related to the delivery. All terms and conditions of this Agreement, including Preauthorization requirements, will apply during any transitional period. Any health care service provided by a Non-Participating Provider under this section shall be covered by Keystone under the same terms and conditions as applicable for Participating Providers. If Keystone terminates the contract of a PCP, Keystone will notify every Member served by that provider of the termination of the contract and will request the Member to select another PCP. Keystone will assist the Member in the selection of another PCP. If the Member does not select another PCP, Keystone may assign the Member to a new PCP. If Keystone terminates the contract of a PCP for cause, including breach of contract, fraud, c...
