Anthem Blue Cross Continuity of Care/Transition of … · Continuity of Care/Transition of Care Request Form ... Continuity of Care/Transition of Care Request Form . Fill out the

Continuity of Care/Transition of Care 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:

o 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.

o 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.

o 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:

o 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;

o If you are in an active course of treatment for any behavioral health condition; o If you are pregnant, regardless of trimester;

o If you have a terminal illness;

o 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;

o 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:

o Call the Customer Care Number on the back of your Anthem Blue Cross card or the Customer Care number provided to you in

open enrollment and they will assist you with completing your request over the phone.

o Or, fax this completed request form to 1-877-214-1781.

To help ensure that your care is not disrupted, please complete the entire form below. Only complete this form if you are receiving

ongoing care or are scheduled for care. For 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 or POS and will stay in your current PMG or IPA, you do not need to complete this

form. If you are in an HMO or POS 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. For Behavioral Health Care: If you

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

Continuity of Care: Application New Enrollee and Application Network Disruptions consolidated herein. Last revised 11/21/14

Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ® ANTHEM is

a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association Anthem Blue Cross

Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association

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Fill out the form completely, and do not leave any blanks. Please use N/A if the information requested does not apply

to your situation. Please complete a separate form for each family member who needs to have care transitioned to another

provider.

Subscriber’s Name: Subscriber’s Anthem Blue Cross ID #:

Subscriber’s Employer: Date Active with Anthem Blue Cross:

Patient’s Name: Relationship to Subscriber:

Date of Birth: Allergies:

Preferred Phone #: Home Work Cell Secondary Phone #: Home Work Cell

Name of Terminating Insurance Plan:

Circle Type of Terminating Plan: HMO Vivity POS PPO EPO CDHP OTHER

New Anthem Blue Cross Plan: HMO Vivity POS PPO EPO CDHP OTHER

Are You a New Enrollee to Anthem Blue Cross: Yes No

Name of PMG/IPA with Terminating Plan: Name of New Anthem Blue Cross PMG/IPA:

For Network Disruption (PMG, IPA, PPO Provider, or Hospital has terminated from the Anthem Blue Cross Participating Provider

Network) please provide the name of the terminating Hospital or Provider:

Diagnosis (include pertinent history and physical findings):

1. Do you have an upcoming appointment to see a specialist? Yes No

If yes, please provide the applicable information below.

Specialist Type Provider

Name (last, first)

Provider Phone Number

Date of Office Visit Reason

Heart Specialist

Lung Specialist

Blood or Cancer Specialist

Neurologist

Infectious Disease Specialist

Kidney Specialist

Behavioral Health Specialist

Orthopedic Specialist

Obstetrician for pregnancy

Due Date:

Hospital for delivery:

Other: Please be specific





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2. Are you currently receiving any of the following services? Yes No

If yes, please provide the applicable information below.

Services Facility or Company, Medical or Behavioral Health Provider

Clinical Laboratory

Oxygen

IV Medication/Chemotherapy

Physical Therapy

Radiation Therapy

Home Therapy

Rehab Treatment

Organ or Stem Cell/Bone Marrow Transplant

Medical Equipment

Medication Management for a Behavioral

Health condition

Dialysis

3. Do you have any hospitalizations, surgeries or procedures scheduled? Yes No

Date Type of Surgery/Procedure

Name/Phone Number of Physician performing surgery/procedure

Hospital/Facility

4. Have you been admitted to the hospital or seen in the emergency room in the past 6 months? Yes No

Reason Hospital

Date(s) of Service

5. Other Needs

I hereby authorize the above provider to give the Anthem Blue Cross Transition Assistance Department any

and all information and medical records necessary to make an informed decision concerning my request for

Transition of Care/Continuity of Care. I understand that I am entitled to a copy of this authorization form.

I also authorize Anthem Blue Cross to leave confidential information on my voice mail at the following

number(s) listed above. Please check all that apply:

Home Cell Work Do NOT leave confidential information on my voice mail

Signature of Patient if 18 or over: Date:

Signature of Parent or Guardian if Patient is under 18: Date:





Formulario de solicitud de continuidad/transición de atención

(Continuity of Care/Transition of Care Request Form)

Continuidad de atención: formulario de nuevo inscrito y formulario de interrupciones de la red consolidados en el presente

documento. Revisado por última vez el 1.° de mayo de 2014.

Anthem Blue Cross es el nombre comercial de Blue Cross of California. Licenciatario independiente de Blue Cross Association.

® ANTHEM es una marca comercial registrada. El nombre y el símbolo de ® Blue Cross son marcas registradas de Blue Cross

Association. Anthem Blue Cross Life and Health Insurance Company es un licenciatario independiente de Blue Cross Association.


(Continuity of Care: Application New Enrollee and Application Network Disruptions consolidated herein. Last revised 05/01/14


a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Blue Cross

Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark.

® The Blue Cross name and symbol are registered marks of the Blue Cross Association.)

INFORMACIÓN GENERAL SOBRE EL PROGRAMA DE ASISTENCIA PARA LA TRANSICIÓN

(GENERAL INFORMATION ABOUT THE TRANSITION ASSISTANCE PROGRAM)

Objetivo de la continuidad/transición de atención

(Purpose of Continuity/Transition of Care)

El Programa de Asistencia para la Transición (Transition Assistance Program) proporciona un proceso para que los miembros

continúen con su atención en los siguientes casos:

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

o Su Grupo Médico Primario (PMG), su Asociación de Médicos Independientes (IPA), su Proveedor de la Organización de

Proveedores Preferidos (Proveedor de PPO), su hospital u otro proveedor deja de formar parte de la red de proveedores

participantes.

(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.)

o Se han inscrito recientemente en un plan de Anthem Blue Cross (con excepción de los miembros que tienen un contrato

individual) y el proveedor que los trata no forma parte de la red de proveedores participantes de Anthem Blue Cross.

(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.) o Se han inscrito recientemente en un plan individual de Anthem Blue Cross y el proveedor que los trata no tiene

contrato para brindar servicios conforme al contrato del plan de la persona inscrita. (They are a new enrollee in an

Anthem Blue Cross Individual plan and their treating provider is not contracted to provide services under the enrollee’s plan contract.)

o La continuidad de atención está en riesgo por motivos que exceden la voluntad del miembro. (Los miembros que hayan

elegido realizar cambios en su cobertura que impliquen estar fuera de la red no son elegibles para este programa).

(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.))

Tenga en cuenta que si usted necesita atención continua para una afección crónica y no atraviesa una etapa aguda de su

enfermedad, que requiera un tratamiento especial, debe elegir un proveedor dentro de la red para atender sus necesidades de

atención de la salud y no deberá completar este formulario. Si necesita ayuda para elegir un nuevo proveedor, comuníquese con

el Servicio de Atención al Cliente de Anthem Blue Cross.

(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.)

Cuándo completar el formulario de solicitud de continuidad/transición de atención

(Completing the Continuity/Transition of Care Request Form)

Usted puede solicitar la continuidad/transición de atención en los siguientes casos:

(You may request Continuity/Transition of Care:)

o Se encuentra bajo tratamiento activo por una afección médica aguda o una afección crónica y grave. Una afección

médica aguda es una afección cuyos síntomas aparecen repentinamente a causa de una enfermedad, una lesión u otro

problema médico. Dicha afección requiere atención médica inmediata y su duración es limitada. Una afección crónica y

grave es una afección médica causada por una enfermedad o por otro problema médico grave, que persiste y no se cura

totalmente, y que empeora con el tiempo; o una afección que requiere tratamiento continuo para mantenerse en remisión

o evitar el deterioro. Pueden seguir proporcionándose los servicios cubiertos durante el tiempo necesario para completar

el tratamiento y para planear la derivación segura a otro proveedor.

(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;)

o Se encuentra bajo tratamiento activo por una afección de la salud del comportamiento.

(If you are in an active course of treatment for any behavioral health condition;)

o Está embarazada (sin importar qué trimestre).

(If you are pregnant, regardless of trimester;)

o Padece una enfermedad terminal.

If you have a terminal illness;

o Tiene un hijo recién nacido de hasta 36 meses de vida. Pueden seguir proporcionándose los servicios cubiertos durante el

tiempo necesario para completar el tratamiento y para planear la derivación segura a otro proveedor.

(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;)

o Debe someterse a una cirugía u otro procedimiento, autorizados por el plan anterior o su proveedor responsable, que

están programados para realizarse dentro de los 180 días de la fecha de entrada en vigencia de la cobertura para una

persona recientemente inscrita.

(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.)

Si una o más de las situaciones mencionadas anteriormente se aplica a su caso y desea saber si reúne los requisitos

para el Programa de Asistencia para la Transición, haga lo siguiente:

(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:)

o Llame al número del Servicio de Atención al Cliente que figura en el reverso de su tarjeta de Anthem Blue Cross o al número

del Servicio de Atención al Cliente que se le indicó en la inscripción abierta, y recibirá asistencia para completar su solicitud

por teléfono.

(Call the Customer Care Number on the back of your Anthem Blue Cross card or the Customer Care number provided to you in open enrollment and they will assist you with completing your request over the phone.)

o O bien, envíe por fax este formulario de solicitud al 1-877-214-1781.

(Or, fax this completed request form to 1-877-214-1781.)














Para asegurarse de que su atención no sea interrumpida, complete el formulario a continuación en su totalidad. Complete este

formulario sólo si recibe atención actualmente o si ha programado recibirla. Para la atención médica: si usted se cambiara a un

plan PPO o EPO y su proveedor médico actual participa en nuestra red; o si usted se cambiara a un plan HMO (Organización para el

Mantenimiento de la Salud) o POS y no planea cambiar de PMG o IPA, no debe completar este formulario. Si tiene un plan HMO o

POS y su proveedor deja de pertenecer al PMG/IPA, no debe completar este formulario, debe comunicarse con su PMG/IPA y lo

ayudarán con la transición a un proveedor que tiene contrato. Para la atención de la salud del comportamiento: si usted

cambiará de plan, y su proveedor no participa en la red de Anthem, complete este formulario.

(To help ensure that your care is not disrupted, please complete the entire form below. Only complete this form if you are receiving

ongoing care or are scheduled for care. For 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 or POS and will stay in your current PMG or IPA, you do not need to complete

this form. If you are in an HMO or POS 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. For Behavioral Health Care: If you are changing plans and your provider is not in the Anthem network, please complete this form.)

Complete el formulario en su totalidad, no deje espacios en blanco. Indique N/A si la información solicitada no se

aplica a su situación. Complete un formulario para cada miembro de la familia que necesite transición de atención con otro

proveedor.

(Fill out the form completely, and do not leave any blanks. Please use N/A if the information requested does not apply

to your situation. Please complete a separate form for each family member who needs to have care transitioned to another provider.)

Nombre del suscriptor: ______________________ N.° de identificación de Anthem Blue Cross del suscriptor:__________________ (Subscriber’s Name:) (Subscriber’s Anthem Blue Cross ID #:)

Empleador del suscriptor: ___________________ Fecha de vigencia con Anthem Blue Cross: _______________________________ (Subscriber’s Employer:) (Date Active with Anthem Blue Cross:)

Nombre del paciente: _______________________ Relación con el suscriptor: ___________________________________________ (Patient’s Name:) (Relationship to Subscriber:)

Fecha de nacimiento: ________________________ Alergias: ________________________________________________________ (Date of Birth:) (Allergies:)

N.° de teléfono preferido: _________ Particular Laboral Celular / N.° de teléfono secundario:___________ Particular Laboral Celular (Preferred Phone #:) (Home Work Cell) (Secondary Phone#:) (Home Work Cell)

Nombre del plan de seguro que deja: ____________Marque con un círculo el tipo de plan que deja: HMO POS PPO EPO CDHP OTRO (Name of Terminating Insurance Plan:) (Circle Type of Terminating Plan: HMO POS PPO EPO CDHP OTHER)

Nuevo plan de Anthem Blue Cross: HMO POS PPO EPO CDHP OTRO ¿Se inscribe por primera vez en Anthem Blue Cross?: Sí No (New Anthem Blue Cross Plan: HMO POS PPO EPO CDHP OTHER) (Are You a New Enrollee to Anthem Blue Cross:) (Yes) (No)

Nombre de PMG/IPA con el plan que deja: _____________ Nombre de PMG/IPA nuevos de Anthem Blue Cross: _________________ (Name of PMG/IPA with Terminating Plan:) (Name of New Anthem Blue Cross PMG/IPA)

Para interrupciones en la red (PMG, IPA, Proveedor de PPO u hospital que ha dejado de la red de proveedores participantes de

Anthem Blue Cross) indique el nombre del hospital o proveedor que deja:

(For Network Disruption (PMG, IPA, PPO Provider, or Hospital has terminated from the Anthem Blue Cross Participating Provider

Network) please provide the name of the terminating Hospital or Provider:)______________________________________________

Diagnóstico (incluya antecedentes pertinentes y resultados de exámenes físicos):

(Diagnosis (include pertinent history and physical findings):)__________________________________________________________

_________________________________________________________________________________________________________














1. ¿Tiene programada una cita con un especialista? Sí No

(Do you have an upcoming appointment to see a specialist? Yes No)

Si respondió "Sí", proporcione la información correspondiente a continuación:

(If yes, please provide the applicable information below.)

Tipo de especialista (Specialist Type)

Nombre del proveedor

(primer nombre, apellido) (Provider Name

(last, first))

Número de

teléfono del proveedor

(Provider

Phone Number)

Fecha de la

visita al consultorio

(Date of Office

Visit)

Motivo (Reason)

Especialista en enfermedades

del corazón

(Heart Specialist) Especialista en enfermedades

del pulmón

(Lung Specialist) Especialista en enfermedades

de la sangre o en cáncer

(Blood or Cancer Specialist) Neurólogo

(Neurologist) Especialista en enfermedades

infecciosas

(Infectious Disease Specialist) Especialista en enfermedades

del riñón

(Kidney Specialist) Especialista en salud del

comportamiento

(Behavioral Health Specialist) Especialista en ortopedia

(Orthopedic Specialist) Obstetra (por un embarazo)

Fecha de parto:

Hospital donde se realizará el

parto:

(Obstetrician for pregnancy

Due Date:

Hospital for delivery:) Otro: (especifique)

(Other: Please be specific)














2. Actualmente, ¿recibe alguno de los siguientes servicios? Sí No

(Are you currently receiving any of the following services? Yes No)

Si respondió "Sí", proporcione la información correspondiente a continuación:

(If yes, please provide the applicable information below.)

Servicios

(Services)

Centro o compañía, proveedor médico o de la salud del comportamiento

(Facility or Company, Medical or Behavioral Health Provider)

Laboratorio clínico

(Clinical Laboratory)

Oxígeno

(Oxygen)

Medicación intravenosa/quimioterapia

(IV Medication/Chemotherapy)

Fisioterapia

(Physical Therapy)

Radioterapia

(Radiation Therapy)

Terapia a domicilio

(Home Therapy)

Tratamiento de rehabilitación

(Rehab Treatment)

Trasplante de órganos o células

madre/médula ósea

(Organ or Stem Cell/Bone Marrow

Transplant)

Equipo médico

(Medical Equipment)

Administración de medicación para un

trastorno de la salud del comportamiento

(Medication Management for a Behavioral

Health condition)

Diálisis

(Dialysis)

3. ¿Ha programado una hospitalización, una cirugía u otro procedimiento? Sí No

(Do you have any hospitalizations, surgeries or procedures scheduled? Yes No)

Fecha _________________ Tipo de cirugía/procedimiento________________________________ (Date) (Type of Surgery/Procedure)

Nombre/teléfono del médico que realizará la cirugía/el procedimiento _______________________________________________ (Name/Phone Number of Physician performing surgery/procedure)

Hospital/centro ________________________________________________ (Hospital/Facility)

4. ¿Ha sido internado en el hospital o ha visitado la sala de emergencias en los últimos 6 meses? Sí No

(Have you been admitted to the hospital or seen in the emergency room in the past 6 months? Yes No)

Motivo _________________________________________________ Hospital ________________________________________ (Reason) (Hospital)

Fecha(s) del servicio ________________________________________ (Date(s) of Service)














5. Otras necesidades___________________________________________________________

(Other Needs)

Por el presente, autorizo al proveedor antes mencionado a proporcionar al Departamento de Asistencia para la Transición (Transition Assistance Department) de Anthem Blue Cross toda la información y los expedientes médicos necesarios para tomar una decisión informada con respecto a mi solicitud de continuidad/transición de atención. Entiendo que tengo derecho a obtener una copia de este formulario de autorización. Además, autorizo a Anthem Blue Cross a dejarme información confidencial en mi correo de voz, a los siguientes

números que figuran más arriba. Marque los que correspondan: __ Casa __ Celular __ Trabajo __ NO dejar información confidencial en mi correo de voz

I hereby authorize the above provider to give the Anthem Blue Cross Transition Assistance Department any

and all information and medical records necessary to make an informed decision concerning my request for

Transition of Care/Continuity of Care. I understand that I am entitled to a copy of this authorization form.

I also authorize Anthem Blue Cross to leave confidential information on my voice mail at the following

number(s) listed above. Please check all that apply: __ Home __ Cell __ Work __ Do NOT leave confidential information on my voice mail

Firma del paciente si tiene 18 años de edad o más: Fecha:

(Signature of Patient if 18 or over:) (Date:)

Firma del padre, de la madre o del tutor si el paciente es menor de 18 años de edad: Fecha:

(Signature of Parent or Guardian if Patient is under 18:) (Date:)

Anthem Blue Cross Continuity of Care/Transition of … · Continuity of Care/Transition of Care Request Form ... Continuity of Care/Transition of Care Request Form . Fill out the

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