UHC Transition of Care

Understanding Transition of Care and Continuity of Care.

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 t o 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 application beginning on page 4.

Continuity of Care

Continuity of Care gives UnitedHealthcare members the option torequest extended care from their current health care professional if he or she is no lon ger 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.

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 Application below.

Your request will be evaluated based on applicable state law and accreditation standards.
If your request is approved for the medical condition(s) listed in your application(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 UnitedHealthcare. All other services or supplies must be provided by a network health care professional for you to receive network coverage levels. If your plan includes out-of network coverage and you choose to continue receiving out-of-network care beyond the time frame approved by UnitedHealthcare, you must follow your plan’s out-of-network requirements, including any prior authorization requirements.
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 in order for a service to be covered.

Examples of medical conditions that may qualify for Transition of Care and Continuity of Care:

Pregnancy (trimester determined by state requirements) through six weeks post-delivery.
– 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.

Examples of conditions that do not qualify for Transition of Care and Continuity of Care:

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:

If my application is approved, how long will I have to transition to a new network health care professional?

If UnitedHealthcare determines that transitioning to a participating health care professional is not recommended or safe for the conditions that qualify for Transition of Care and Continuity of Care, services by the approved out of-network health care professional will be authorized at the network level of benefits for a specified period of time or until care has been completed or transitioned to a participating health care professional, whichever comes first. You must apply 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, or you will not be eligible for the Transition of Care and Continuity of Care service.*

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 Transition of= Care/Continuity of Care coverage for more than one medical condition, you should complete a Transition of Care/Continuity of Care Application for each specific condition within 30 days after your coverage becomes effective or your health care professional leaves the UnitedHealthcare network.*

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 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.

Learn More