Continuity of Care/Transition Request Form

GENERAL INFORMATION ABOUT THE TRANSITION ASSISTANCE PROGRAM

Purpose of Continuity/Transition of Care

The Transition Assistance Program provides a process that allows continued care for members when:

• Their Primary Medical Group (PMG), Independent Physician Association (IPA), Preferred Provider Organization Provider (PPO Provider), Hospital, or other provider is terminated from the Anthem Blue Cross participating provider network.
• They are a new enrollee in an Anthem Blue Cross plan (except members with an Individual contract) and their treating provider is not part of the Anthem Blue Cross participating provider network.
• Continuity of care is at risk for reasons over which the member has no control.  (Members who have elected to make changes in their coverage which cause them to be out-of-network are not eligible for this program).

Please Note: If you require ongoing care for any chronic condition and you are not in an acute phase of your illness, one requiring a special course of treatment, you should select an in-network provider to meet your ongoing health care needs and you do not need to complete this form.If you need assistance selecting a new provider you should contact Anthem Blue Cross Customer Care.

Completing the Continuity/Transition of Care Request Form 

You may request Continuity/Transition of Care:

• If you are in an active course of treatment for an acute medical condition or a serious chronic condition. An acute medical condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem that requires prompt medical attention and that has a limited duration. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem that is serious in nature and that persists without full cure or worsens over time or one that requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services may be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider;
• If you are in an active course of treatment for any behavioral health condition;
•  If you are pregnant, regardless of trimester;
• If you have a terminal illness;
• If you have a newborn child between the ages of birth and 36 months. Completion of covered services may be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider;
• If you have a surgery or other procedure that has been authorized by the previous plan or its delegated provider and is scheduled to occur within 180 days of the effective date of coverage for a newly covered enrollee.

If one or more of the above situations applies to you and you would like to see if you are eligible for the Transition Assistance Program, please:

• Call the Customer Care Number on the back of your UC SHIP card or the Customer Care number provided to you in by the campus and they will assist you with completing your request over the phone.
• Or, fax this completed request form to 1-877-214-1781.

To help ensure that your care is not disrupted, please click undergraduate or graduate. Only complete this form if you are receiving ongoing care or are scheduled for care.

Medical Care.

• If you are changing to a PPO or EPO and your current medical provider is in our network, or if you are changing to an HMO and will stay in your current PMG or IPA, you do not need to complete this form.
• If you are in a HMO and your provider is leaving the PMG/IPA, you do not need to complete this form, you need to contact your PMG/IPA and they will assist you with your transition to a contracting provider;

Behavioral Health Care:

• If you are changing plans and your provider is not in the Anthem network, please download and  complete this form.