What is Continuity of Care?

Continuity of Care (COC) is a health plan process that, under certain conditions, provides members with short-term, temporary coverage for care received from a former, non-participating provider. The Continuity of Care process acts as a “bridge to coverage” for those in the middle of an “active course of treatment” as you transition from your old plan to your new plan.

Things to Know about Continuity of Care

• If you or a member of your family qualifies for COC, complete the appropriate COC request form as soon as possible, but not later than thirty (30) days of your effective date of enrollment. Exceptions to the 30-day time frame will be considered for good cause.
• Temporary coverage with a non-participating provider may be authorized in those cases in which a change in physician could adversely affect you or your dependent’s medical care.
• A preference for a particular physician or ongoing monitoring for a chronic condition will not qualify you for Continuity of Care.
• If you do not receive preauthorization by Trinity or by your chosen medical group/IPA, payment for services rendered by a non-participating provider will be your responsibility.

Members may be eligible for Continuity of Care for at least 90 days from date of notification letter if they have one of the following conditions:

• Pregnancy – undergoing a course of treatment for pregnancy.
• Mental Health/Substance Abuse Care – must be an acute episode receiving active treatment.
• Terminal Medical Condition or Illness
• Serious and Complex Condition – a serious and complex condition means: in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or in the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital; and requires specialized medical care over a prolonged period of time.
• Institutional or Inpatient Care – undergoing a course of institutional or inpatient care.
• Scheduled Non-Elective Surgery – scheduled to undergo non-elective surgery, including post-operative care with respect to such a surgery.
• Any other condition eligible for Continuity of Care in accordance with applicable laws.

How to apply for Continuity of Care:

• If you think you or a member of your family qualifies for Continuity of Care, complete the Continuity of Care form (please see link below) as soon as possible.
• Upon receipt of the completed form, the company’s Health Services department will complete a COC review. The decision will be made and communicated to you in a timely manner appropriate for the nature of your condition. In most instances, decisions for non-urgent requests will be made within five (5) business days of the company’s receipt of your completed form.
• You will be notified by telephone and provided with a plan for your continued care.

If you have any questions regarding the medical process, please call WellFit at (888) 297-9423. If your questions are pharmacy related, please call Intercept Rx at (888) 960-0668.

WellFit Continuity of Care Form

Intercept Rx Continuity of Care Form