Surest Transition of Care
Understanding Transition of Care and Continuity of Care
Transition of Care
Transition of Care gives new Surest 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 condition until the safe transfer to a network health care professional can be arranged. Examples of covered 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 Surest coverage begins using the form beginning on page 4.
Continuity of Care
Continuity of Care gives Surest members the option to request extended care from their current health care professional if they are no longer working with their health plan and are now considered outof-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 conditions for a defined period of time.
How Transition of Care and Continuity of Care work:
You must already be under active and current treatment (see definition below) by the identified noncontracted 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, State law, and accreditation standards.
- 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 a defined time frame, as determined by Surest.
- 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.
- 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 conditions that may qualify for Transition of Care and Continuity of Care include, but are 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
- Ongoing mental health treatments
- Other serious chronic conditions that require active treatment
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 (except as required by state law)
- Minor illnesses such as colds, sore throats, and ear infections
- Elective scheduled surgeries (except as required by state law)
Frequently asked questions:
Definitions
Transition of Care: Gives new Surest members the option to request extended coverage from their current, outof-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 Surest members the option to request extended care from their current health care professional if they are no longer working with their health plan and are 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.