Having troble nderstanding some of the health insrance terms on this form? See definitions on page 3. Transition of Care/ Continity of Care Overview Transition of care gives new UnitedHealthcare members the option to reqest extended coverage from their crrent, ot-of-network health care professional at network rates for a limited time de to a specific medical condition ntil the safe transfer to a network health care professional can be arranged. Examples of covered medical conditions can be fond at the end of this page.yo mst apply for transition of care no later than 30 days after the date yor UnitedHealthcare coverage begins sing the application beginning on page 4. Continity of care gives UnitedHealthcare members the option to reqest extended care from their crrent health care professional if he or she is no longer working with their health plan and is now considered ot-of-network. Members with medical reasons preventing an immediate transfer to a network health care professional may reqest extended coverage for services at network rates for specific medical conditions for a defined period of time. Examples of covered medical conditions can be fond on page 2 of this docment. If yor health care professional is leaving the UnitedHealthcare network, yo mst apply for continity of care within 30 days of the health care professional s termination date sing the application beginning on page 4. M52839 12/14 2014 United HealthCare Services, Inc.
How Transition of Care/Continity of Care Works Yo mst already be nder active and crrent treatment (see definition below) by the identified non-contracted health care professional for the condition identified on the Transition of Care/Continity of Care Application below. Yor reqest will be evalated based on applicable state law and accreditation standards. If yor reqest is approved for the medical condition(s) listed in yor application(s), yo will receive the network level of coverage for treatment of the specific condition(s) by the health care professional for a defined time frame, as determined by UnitedHealthcare. All other services or spplies mst be provided by a network health care professional for yo to receive network coverage levels. If yor plan incldes ot-of-network coverage and yo choose to contine receiving ot-of-network care beyond the timeframe approved by UnitedHealthcare, yo mst follow yor plan s ot-of-network reqirements, inclding any prior athorization reqirements. The availability of transition of care/continity of care coverage does not garantee that a treatment is medically necessary or is covered by yor plan benefits,. Depending on the actal reqest, a medical necessity determination and formal prior athorization may still be reqired in order for a service to be covered. Examples of medical conditions that may qalify for transition of care/continity of care inclde: Pregnancy (trimester determined by state reqirements) throgh six weeks postdelivery Transition of care for the mother does not apply to the newborn. If the care provider or facility is ot-ofnetwork for the newborn, please sbmit a network gap reqest for services for the newborn by calling the nmber on yor member ID card. Newly diagnosed or relapsed cancer and crrently receiving chemotherapy, radiation therapy or reconstrction Transplant candidates, transplant recipients or transplant recipients in need of ongoing care de to complications associated with a transplant [now that we have removed nstable the second and third options are confsing. Do we mean to say that all transplant recipients may qalify?] Recent major srgeries in the acte phase and follow-p period (generally six to eight weeks after srgery) Serios acte conditions in active treatment sch as heart attacks or strokes Other serios chronic conditions that reqire active treatment. Examples of conditions that do not qalify for transition of care/continity of care inclde: Rotine exams, vaccinations and health assessments Chronic conditions sch as diabetes, arthritis, allergies, asthma, kidney disease and hypertension that are stable Minor illnesses sch as colds, sore throats and ear infections Elective schedled srgeries (except as reqired by state law) 2
Freqently Asked Qestions: Q1. If my application is approved, how long will I have to transition to a new network health care professional? A. If UnitedHealthcare determines that transitioning to a participating health care professional is not recommended or safe for the conditions that qalify for transition of care/continity of care, services by the approved ot-of-network health care professional will be athorized at the network level of benefits for a specified period of time or ntil care has been completed or transitioned to a participating health care professional, whichever comes first. Yo mst apply for transition of care/continity of care within 30 days of the effective date of coverage or within 30 days of the care provider s termination date, or yo will not be eligible for the transition of care/continity of care service. Q2. If I am approved for transition of care/continity of care for one medical condition, can I receive network coverage for a non-related condition? A. No. Network coverage levels provided as part of transition of care/continity of care are for the specific medical conditions only and cannot be applied to another condition. If yo are seeking transition of care/continity of care coverage for more than one medical condition, yo shold complete a Transition of Care/Continity of Care Application for each specific condition within 30 days after yor coverage becomes effective or yor health care professional leaves the UnitedHealthcare network. Definitions: Transition of Care: Gives new UnitedHealthcare members the option to reqest extended coverage from their crrent, ot-of-network health care professional at network rates for a limited time de to a specific medical condition, (see examples below) ntil the safe transfer to a network health care professional can be arranged. Continity of Care: Gives UnitedHealthcare members the option to reqest extended care from their crrent health care professional if he or she is no longer working with their health plan and is now considered ot-ofnetwork. Network: The facilities, providers and sppliers yor health plan has contracted with to provide health care services. Ot-of-Network: Services provided by a non-participating provider Pre-Athorization: An assessment for coverage nder yor health plan before yo can get access to medicine or services. Active Corse of Treatment: An active corse of treatment typically involves reglar visits with the practitioner to monitor the stats of an illness or disorder, provide direct treatment, prescribe medication or other treatment or modify a treatment plan. Discontining an active corse of treatment cold case a recrrence or worsening of the condition nder treatment and interfere with recovery. Generally an active corse of treatment is defined as within the last 30 days, bt is evalated on a case by case basis. See other health care and health insrance terms and definitions at jstplainclear.com. 3
Transition of Care/ Continity of Care Application This form is for all flly-insred members except for members residing in California, North Carolina or Soth Carolina. To complete this application: Please make sre all fields are completed. When the application is complete, it mst be signed by the member for whom the transition of care/continity of care is being reqested. If the patient is a minor, a gardian s signatre is reqired. Yo mst apply for transition of care/continity of care within 30 days of the effective date of coverage or within 30 days of the care provider s termination date. A separate Transition of Care/Continity of Care Application mst be completed for each condition for which yo and/or yor dependents are seeking transition of care/continity of care. Please mail or fax the completed application along with relevant medical records and information within 30 days following the effective date of yor UnitedHealthcare plan to: UnitedHealthcare 1311 W, President George Bsh Hwy, Richardson, TX 75080-1133 Attn: Transition of Care/Continity of Care Fax 800-628-0654 After receiving yor reqest, UnitedHealthcare will review and evalate the information provided and send yo a letter to let yo know if yor reqest was approved or denied. Completion of this application does not garantee that a transition of care/continity of care reqest will be granted. For behavioral health services, please contact yor behavioral health carrier by calling the Cstomer Services phone nmber on the back of yor health care ID card New UnitedHealthcare member (transition of care applicant) Existing UnitedHealthcare member whose care provider terminated (continity of care applicant) Member Information Name UnitedHealthcare Member ID Nmber Date of Birth (mm/dd/yyyy) Address City State/ZIP Code Home/Cell Phone Nmber Work Phone Nmber Employer Name Member s Relationship to Employee Self Spose Dependent Other Date of Enrollment in the UnitedHealthcare Plan (mm/dd/yyyy) Is the member crrently covered by other health insrance carrier? Yes No If yes, carrier name: Athorization to release records: I athorize all physicians and other health care professionals or facilities to provide UnitedHealthcare information concerning medical care, advice, treatment or spplies for the member named above. This information will be sed to determine the member s eligibility for transition of care/contination of care benefits nder the plan. Member s Signatre/Parent or Gardian s Signatre if Member is a Minor Date (mm/dd/yyyy) 4
Care Provider Section: Yor health care professional shold complete the following information. Name National Provider Identifier (NPI) or Tax ID Nmber (TIN) Phone Nmber Address City State/ZIP Code Hospital Hospital Phone Nmber Date of Last Visit (mm/dd/yy) Next Schedled Appointment (mm/dd/yy) Freqency of Visits Diagnosis Expected Length of Treatment If Maternity: Expected Date of Delivery (mm/dd/yyyy) Please select one of the descriptions if it applies: Life Threatening Condition Acte Condition Transplant Inpatient/Confined Upcoming Srgery Disabled/Disability Terminal Illness Ongoing Treatment Newborn members: Transition of care for the mother does not apply to the newborn. If the health care professional or facility is ot of network for the newborn, please sbmit a network gap reqest for services for the newborn by calling the nmber on the back of the member ID card. Is the treatment for an exacerbation of a previos injry or chronic condition? Yes No Crrent and Associated Treatment(s)/Comments If these care needs are not associated with the condition for which yo are applying for transition of care/continity of care coverage, please complete a separate Transition of Care/Continity of Care Application for each condition. The above-named patient is a UnitedHealthcare member. We nderstand yo are not, or soon will not be, a participating provider in the UnitedHealthcare network. The member has asked that for a defined period of time we treat claims as network nder the member s benefit plan for the covered services yo provide as a non-participating provider. This is becase of a qalifying condition. If we approve this reqest, yo agree (1) to provide the covered service, inclding any follow-p care covered nder the member s plan, and (2) if applicable, the terms and conditions of yor participation agreement will contine to apply to the covered service, inclding any follow-p care covered nder the member s plan. Please note the following: If applicable, payment nder yor participation agreement, together with any copayment, dedctible or coinsrance for which the member is responsible nder the plan is payment in fll for the covered service and yo will not seek to recover, and will not accept any payment from the member, UnitedHealthcare, or any payer or anyone acting on their behalf, in excess of payment in fll, regardless of whether sch amont is less than yor billed or cstomary charge. Upon reqest, yo will share information regarding the member s treatment with s. If applicable, yo will make referrals for services inclding laboratory services, to network providers in accordance with the terms of yor participation agreement. Signatre of Health Care Professional Date (mm/dd/yyyy) CONFIDENTIALITY NOTICE: Information in this docment is considered to be UnitedHealthcare s confidential and/or proprietary bsiness information. Conseqently, this information may be sed only by the person or entity to which it is addressed. Any recipient shall be liable for sing and protecting UnitedHealthcare s proprietary bsiness information from frther disclosre or misse, consistent with recipient s contractal obligations nder any applicable administrative services agreement, grop policy contract, non-disclosre agreement or other applicable contract or law. The information yo have received may contain protected health information (PHI) and mst be handled according to applicable state and federal laws, inclding, bt not limited to HIPAA. Individals who misse sch information may be sbject to both civil and criminal penalties. Any person who knowingly and with intent to defrad any insrance company or other person files an application for insrance or statement of claim containing any materially false information, or conceals for the prpose of misleading, information concerning any fact material thereto, may commit a fradlent insrance act, which may be a crime, and may also be sbject to a civil penalty for each violation 5