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If you're new to Cigna or changing plans and your provider is outside your new Cigna plan's network, or if you are a current customer and your provider is leaving your plan's network, Transition or Continuity of Care may allow you to see them for a defined amount of time if you have certain medical conditions.
What is Transition of Care?
With Transition of Care, you may be able to continue to receive services for specified medical and behavioral conditions with health care providers who are not in your plan’s network at in-network coverage levels. This care is for a defined period of time until the safe transfer of care to an in-network doctor or facility can be arranged. You must apply for Transition of Care at enrollment, or when there is a change in your Cigna medical plan. You must apply no later than 30 days after the effective date of your coverage.
What is Continuity of Care?
With Continuity of Care, you may be able to receive services at in-network coverage levels for specified medical and behavioral conditions when your health care provider leaves your plan's network. There must be solid clinical reasons preventing immediate transfer of care to another health care provider. This care is for a defined period of time. You must apply for Continuity of Care within 30 days of your health care provider's termination date. This is the date that they are leaving the Cigna network.
If you are enrolled in a Cigna HealthCare of California, Inc. HMO or Network plan and reside in California, the above information may not apply to you.
How Continuity and Transition of Care work
- You must already be under treatment for the condition identified on the Transition of Care/Continuity of Care request form
- If the request is approved for medical or behavioral conditions:
- The level of coverage for the treatment of the specific condition will be defined in your policy/ service agreement or plan documents. If you have questions regarding coverage and potential responsibility for charges, please discuss this with the case manager assigned to you (if you do not have a case manager, please call Cigna directly).
- Your plan may not include out-of-network coverage. If that is the case, and you choose to continue care out-of-network beyond the time frame approved by Cigna, you may not have coverage for those services. Please check your plan documents for covered and non-covered services.
- Transition of Care/Continuity of Care applies only to the treatment of the medical condition specified and the health care professional identified on the request form. (All other conditions must be cared for by an in-network health care professional for you to receive in-network coverage.)
- The availability of Transition of Care/Continuity of Care:
- Does not guarantee that a treatment is medically necessary
- Does not constitute precertification of medical services to be provided
- Depending on the actual request, a medical necessity determination and formal precertification may still be required for a service to be covered
What conditions qualify for Transition or Continuity of Care?
Examples of acute medical and behavioral conditions that may qualify for Transition of Care/Continuity of Care include, but are not limited to:
- Hospital confinement on the plan effective date (only for those plans that do not have extension of coverage provisions)
- Acute conditions in active treatment such as heart attacks, strokes or unstable chronic conditions
- "Active treatment" is defined as a doctor visit or hospital stay with documented changes in a therapeutic regimen. This is within 21 days prior to your plan effective date or your health care provider's termination date
- Recent major surgeries still in the follow-up period, that is generally six to eight weeks
- Transplant candidates, unstable recipients or recipients in need of ongoing care due to complications associated with a transplant
- Newly diagnosed or relapsed cancer in the midst of chemotherapy, radiation therapy or reconstruction
- Pregnancy is considered "high risk" if mother’s age is 35 years or older, or patient has or had:
- Early delivery (three weeks) in previous pregnancy.
- Gestational diabetes – pregnancy induced hypertension
- Multiple inpatient admissions during this pregnancy
- Multiple inpatient admissions during this pregnancy
- Pregnancy induced hypertension.
- Pregnancy in the second or third trimester at the time of the plan effective date or of the health care provider termination What does not qualify?
- Routine exams, vaccinations and health assessments
- Stable chronic conditions such as diabetes, arthritis, allergies, asthma, hypertension, and glaucoma
- Acute minor illnesses such as colds, sore throats, and ear infections
- Elective scheduled surgeries such as removal of lesions, bunionectomy, hernia repair, and hysterectomy
Frequently Asked Questions
What time frame is allowed for transitioning to a new in-network health care provider?
If Cigna determines that transitioning to an in-network health care provider is not recommended or safe for the conditions that qualify, services by the approved out-of-network health care provider will be authorized for a specified period of time (usually 90 days). Or, services will be approved until care has been completed or transitioned to an in-network health care provider, whichever comes first.
If I am approved for Transition of Care/Continuity of Care for one illness, can I receive in-network coverage for a non-related condition?
Authorizations provided as part of Transition of Care/Continuity of Care are for the specific illness or condition only and cannot be applied to another illness or condition. You need to complete a Transition of Care/Continuity of Care request form for each unrelated illness or condition. You need to complete this form no later than 30 days after your plan becomes effective or your health care provider leaves your plan’s network.
Can I apply for Transition of Care/Continuity of Care if I am not currently in treatment or seeing a health care provider?
You must already be in treatment for the condition that is noted on the Transition of Care/Continuity of Care request form.
How do I apply for Transition of Care/Continuity of Care coverage?
Requests must be submitted in writing, using the Transition of Care/Continuity of Care request form. This form must be submitted at the time of enrollment, change in Cigna medical plan, or when your health care provider leaves the Cigna network. It cannot be submitted more than 30 days after the effective date of your plan or your health care provider’s termination. After receiving your request, Cigna will review and evaluate the information provided. Then we will send you a letter informing you whether your request was approved or denied. A denial will include information about how to appeal the determination.