Transition and Continuity of Care Benefits

Transition of Care Benefits – For New Plan Members

Transition of Care Benefits allow covered services from an out of network provider to be covered at the in-network benefit level of a patient’s plan for specific situations where treatment began under a previous carrier and is expected to continue. 

Examples of items that may qualify for transition of care include pregnancy in the second or third trimester, patients who are hospitalized prior to their new coverage effective date, terminal illness where life expectancy is less than six months or long-term treatment of cancer, heart disease and transplants. 

Continuity of Care Benefits – For Existing Plan Members

Continuity of Care is an authorization that allows a patient to continue care under special circumstances with a provider that is (or within 30 days will be) out of network. This authorization allows coverage at the in-network level of the patient’s plan when the treating provider’s contract with the network terminates. 

The following requirements must be met for continuity of care to be approved:

• The provider must be out of network.
• The patient must have an acute condition (not an on-going, chronic condition).
• The condition must be serious (requiring intense medical treatment) and have a finite course of treatment.

If you have questions about Transition of Care or Continuity of Care benefits, contact a Blue Cross and Blue Shield of Illinois Benefit Value Advisor by calling 1-800-325-0320.