Understanding
Transition of Care and
Continuity of Care.
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Transition of Care
Transition of Care gives new UnitedHealthcare members the option
to request extended coverage from their current, out-of-network
health care professional at network rates for a limited time due to a
specific medical condition until the safe transfer to a network health
care professional can be arranged. Examples of covered medical
conditions can be found on page 2 of this document. You must
apply for
Transition of Care no later than 30 days after the date your
UnitedHealthcare coverage begins using the form beginning on
page 4.
Continuity of Care
Continuity of Care gives UnitedHealthcare members the option to
request extended care from their current health care professional if
he or she is no longer working with their health plan and is
now considered out-of-network. Members with medical reasons
preventing an immediate transfer to a network health care
professional may request extended coverage for services at
network rates for specific medical conditions for a defined period of
time.
Get help with understanding
these health insurance terms
and more on page 3.
Examples of covered medical conditions
can be found on page 2 of this document.
If your health care professional is leaving the UnitedHealthcare
network, or if you are a new UnitedHealthcare member, you
must apply for Continuity of Care or Transition of Care within
30 days of the health care professional’s termination date or
within 30 days of your effective date, using the form beginning
on page 4.
UnitedHealthcare
How Transition of Care and Continuity of Care works:
You must already be under active and current treatment (see definition below) by the identified
non-contracted health care professional for the condition identified on the Transition of Care
and Continuity of Care form below.
Your request will be evaluated based on applicable Federal law, plan benefits and
accreditation standards. Coverage at the network level is available if the provider agrees to
accept our network rates, provide medical records, follow our policies and a treatment plan
approved by us.
• If your request is approved for the medical condition(s) listed in your form(s), you will receive
the network level of coverage for treatment of the specific condition(s) by the health care
professional for:
o Up to 30 days from the effective date of coverage for new members,
o Up to 90 days from when your provider leaves your health plan network, or
o through completion of the current active course of treatment period, whichever
comes first
• If your request is received after the above time-frames, you will not be eligible for Transition of
Care or Continuity of Care.
• After this time, network coverage ends. If your plan includes out-of-network coverage and you
choose to continue receiving out-of-network care beyond the time frame we approve, you
must follow your plan’s out-of-network requirements, including any prior authorization or
notification requirements.
• All other services or supplies must be provided by a network health care professional for you
to receive network coverage levels.
• If your plan does not include out-of-network coverage, you can call the number on the back of
your health plan ID card for assistance.
• The availability of Transition of Care and Continuity of Care coverage does not guarantee that
a treatment is medically necessary or is covered by your plan benefits. Depending on the
actual request, a medical necessity determination and formal prior authorization may still be
required for a service to be covered.
Examples of medical conditions that may qualify for Transition of
Care and Continuity of Care includes, but is not limited to:
• Pregnant and undergoing a course of treatment for pregnancy.
– Coverage for newborn children begins at the moment of birth and continues for 30 days. You
must select an in network pediatrician and notify your health plan representative within 30 days
from the baby’s date of birth to add the baby to your plan.
• Newly diagnosed or relapsed cancer and currently receiving chemotherapy, radiation therapy
or
reconstruction.
• Transplant candidates or transplant recipients in need of ongoing care due to complications
associated with a transplant.
• Recent major surgeries in the acute phase and follow-up period (generally six to eight weeks after
surgery).
• Serious acute conditions in active treatment such as heart attacks or strokes.
• Other serious chronic conditions that require active treatment.
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Q
A
Frequently asked questions:
Q
A
What can I expect after the completed form
is submitted?
You will receive a written decision either approving or denying your request. We encourage
you to find a doctor, health care professional or facility (like a hospital) in your network at
myuhc.com.
If I am approved for Transition of Care and Continuity of Care for one medical condition, can I
receive network coverage for a non-related condition?
No. Network coverage levels provided as part of Transition of Care and Continuity of Care
are for the specific medical conditions only and cannot be applied to another condition. If
you are seeking network level of benefits for more than one medical condition, you will
need to complete a separate request for each specific condition.
Definitions:
Transition of Care: Gives new UnitedHealthcare members the option to request extended coverage from their
current, out-of-network health care professional at network rates for a limited time due to a specific medical condition,
until the safe transfer to a network health care professional can be arranged.
Continuity of Care: Gives UnitedHealthcare members the option to request extended care from their current health
care professional if he or she is no longer working with their health plan and is now considered out-of-network.
Network: The facilities, providers and suppliers your health plan has contracted with to provide health care services.
Out-of-network: Services provided by a non-participating provider.
Pre-authorization: An assessment for coverage under your health plan before you can get access to medicine
or services.
Active course of treatment: An active course of treatment typically involves regular visits with the practitioner to
monitor the status of an illness or disorder, provide direct treatment, prescribe medication or other treatment or modify
a treatment plan. Discontinuing an active course of treatment could cause a recurrence or worsening of the condition
under treatment and interfere with recovery. Generally an active course of treatment is defined as within the last 30
days, but is evaluated on a case-by-case basis.
See other health care and health insurance terms and definitions at justplainclear.com.
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Examples of conditions that do not qualify for
Transition of Care and Continuity of Care include:
• Routine exams, vaccinations and health assessments.
• Chronic conditions such as diabetes, arthritis, allergies, asthma, kidney disease and hypertension
that are stable.
• Minor illnesses such as colds, sore throats and ear infections.
• E
lective scheduled surgeries.
Authorization to release records:
Transition of Care and Continuity of Care Form
This form is for self-funded members only.
For behavioral health services, please contact your behavioral health carrier by
calling the Customer Service phone number on your health plan ID card.
To complete this form:
• Please make sure all fields are completed. When the form is complete, it must be signed by the member for whom
the Transition of Care and Continuity of Care is being requested. If the patient is a minor, a guardian’s signature is
required.
• You must complete and submit the form for Transition of Care and Continuity 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 and Continuity of Care form must be completed for each condition for which you and/or
your dependents are seeking Transition of Care and Continuity of Care.
• Please mail or fax the completed form along with relevant medical records and information, within 30 days following
the effective date of your UnitedHealthcare plan to:
UnitedHealthcare
600 Airborne Parkway
Cheektowaga, NY 14225
Attn: Transition of Care/Continuity of
Care Fax: 855-686-3561
• After receiving your request, UnitedHealthcare will review and evaluate the information provided. Incomplete forms will
be returned to the requestor. If the form is complete, we will send you a letter to let you know if your request was
approved or denied. Completion of this form does not guarantee that a Transition of Care and Continuity of Care
request will be granted.
Member Information
New UnitedHealthcare member (Transition of Care applicant)
Existing UnitedHealthcare member whose care provider terminated
(Continuity of Care applicant)
Provider Termination Date
Name (Person being treated) UnitedHealthcare Member ID Number Date of Birth (mm/dd/yyyy)
Address City State/ZIP Code
Home/Cell Phone Number Work Phone Number
Employer Name Date of Enrollment in the UnitedHealthcare Plan (mm/dd/yyyy)
Member’s Relationship to Employee
Self Spouse
Dependent Other
Is the member currently covered by other health insurance carrier?
Yes No
If yes, carrier name:
I authorize all physicians and other health care professionals or facilities to provide UnitedHealthcare information concerning medical care,
advice, treatment or supplies for the member named above. This information will be used to determine the member’s eligibility for Transition
of Care/Continuity of Care benefits under the plan.
Member’s Signature/Parent or Guardian’s Signature if Member is a Minor Date (mm/dd/yyyy)
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Care Provider Section: Your health care professional should complete the following information.
Name (Treating Physician or other
Healthcare Professional)
National Provider Identifier (NPI) or
Tax ID Number (TIN)
Phone Number
Address City State/ZIP Code
Facility Name, NPI or TIN, City and State
Facility Phone Number
Date of Last Visit
(mm/dd/yyyy)
Next Scheduled Appointment
(mm/dd/yyyy)
Frequency of Visits
Diagnosis Expected Length of Treatment If Maternity: Expected Date of Delivery
(mm/dd/yyyy)
Please select 1 of the descriptions if it applies:
Life-Threatening Condition Acute Condition Transplant Inpatient/Confined
Upcoming Surgery Disabled/Disability Terminal Illness Ongoing Treatment
Newborn members: Coverage for newborn children begins at the moment of birth and continues for 30 days. You must select a network
pediatrician and notify your health plan representative within 30 days from the baby’s date of birth to add the baby to your plan.
Is the treatment for an exacerbation of a previous injury or chronic condition? Yes
No
Current Condition and Associated Treatment Plan (include brief statement and all relevant CPT codes)*
If these care needs are not associated with the condition for which you are requesting Transition of Care and Continuity of Care coverage,
please complete a separate Transition of Care and Continuity of Care form for each condition. *attached additional clinical as needed.
We understand you are not, or soon will not be, a participating provider in our network. Our member is receiving treatment for the above
medical condition from you and is seeking continued coverage at the network benefit level. If the member is eligible, you agree to (1)
provide the covered service, including any follow-up care covered under the member’s plan, for the applicable time-frame, (2) follow our
policies and procedures, (3) upon request, share information regarding the member’s treatment with us, (4) if applicable, make referrals
for services, including laboratory services to network providers, or ask for our approval before referring a member to an out-of-network
provider, and (5) if applicable, request any required prior approval before the services are rendered. Please note the
following:
For providers leaving our network: The terms and conditions of your participation agreement will continue to apply to the covered
service, including any follow-up care covered under the member’s plan. Payment under your participation agreement, along with any
co-payment, deductible or coinsurance for which the member is responsible under the plan, is payment in full for the covered service.
You will neither seek to recover nor accept any payment in excess of this amount from the member, us, or any payer or anyone acting on
their behalf, regardless of whether such amount is less than your billed or customary charge.
For out-of-network providers seeing new members: If the member is eligible, we will provide coverage at the network benefit level.
Payment will be consistent with the member’s benefit plan. If coverage at the network benefit level is available, you agree to accept
payment from us along with any co-payment, deductible or coinsurance for which the member is responsible under the plan as payment
in full for the covered service. You will neither seek to recover nor accept any payment in excess of this amount from the member, us, or
any payer or anyone acting on their behalf, regardless of whether such amount is less than your billed or customary charge.
Signature of Health Care Professional Date (mm/dd/yyyy)
CONFIDENTIALITY NOTICE: Information in this document is considered to be UnitedHealthcare’s confidential and/or proprietary business inf
ormation. Consequently, this information may be used only by the
person or entity to which it is addressed. Any recipient shall be liable for using and protecting UnitedHealthcare’s proprietary business information from further disclosure or misuse, consistent with recipient’s
contractual obligat
ions under any applicable administrative services agreement, group policy contract, non-disclosure agreement or other applicable contract or law. The information you have received may
contain protected health information (PHI) and must be handled according to applicable state and federal laws, including, but not limited to HIPAA. Individuals who misuse such information may be subject to
both civil and criminal penalties.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, may commit a fraudulent insurance act, which may be a crime, and may also be subject to a civil penalty for each violation.
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5
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UnitedHealthcare
®
We do not treat members dierently because of sex, age, race, color,
disability or national origin. If you think you were treated unfairly
because of your sex, age, race, color, disability or national origin, you
can send a complaint to the Civil Rights Coordinator.
(Arabic)
Online: [email protected]
Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights
Grievance. P.O. Box 30608, Salt Lake City, UT 84130
You must send the complaint within 60 days of when you found
out about it. A decision will be sent to you within 30 days. If you
disagree with the decision, you have 15 days to ask us to look at it
again.
If you need help with your complaint, please call the toll-free phone
number listed on your ID card, TTY 711, Monday through Friday,
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You can also le a complaint with the U.S. Dept. of Health and
Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/oce/le/
index.html.
Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services, 200 Independence
Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201
We provide free services to help you communicate with us, such
as letters in other languages or large print. Or, you can ask for an
interpreter. To ask for help, please call the toll-free phone number
listed on your ID card, TTY 711, Monday through Friday, 8 a.m.
to 8 p.m.
ATTENTION: If you speak English, language assistance services,
free of charge, are available to you. Please call the toll-free phone
number listed on your identication card.
ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia
de idiomas, sin cargo, a su disposición. Llame al número de teléfono
gratuito que aparece en su tarjeta de identicación.
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được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng
gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.
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makukuha kang mga libreng serbisyo ng tulong sa wika.
Pakitawagan ang toll-free na numero ng telepono na nasa iyong
identication card.
ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab
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nimewo gratis ki sou kat idantikasyon w.
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linguistique vous sont proposés gratuitement. Veuillez appeler le
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lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga
aqoonsiga.
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