Commercial Customer Experience Team Continuity of Care Application 2550 S. Parker Rd. Aurora, CO Phone: (303) Fax: (303)

Transcription

1 Commercial Customer Experience Team Continuity of Care Application 2550 S. Parker Rd. Aurora, CO Phone: (303) Fax: (303) Dear New Member, Thank you for choosing Kaiser Permanente. As a new member or current member changing benefit plans, you may be concerned about how you will be able to complete any medical treatments that were started before you changed your health plan. Kaiser Permanente wants to insure that there are no gaps in your care as you move from your current providers (physicians or facilities). If you would like to make a formal request for Kaiser Permanente and Kaiser Permanente Insurance Company (KPIC) to cover transitional care and treatment for a specified medical condition for a limited time, from a non-participating provider, please follow these instructions for how to submit the following application form. This is what you need to do: Please fill out this form completely and mail or fax it as listed above. Make sure that your application is postmarked or fax-dated no less than 20 calendar days prior to the effective date of your new plan. We will review your request and let you know by mail no later than your new plan s effective date, about the determination of your request for time-limited transitional care. Please see the associated policy for events that may impact this process. Please complete and sign Section II of this application. Have the non-participating provider who is treating your condition complete and sign Section III of this application. Please fill out a separate form for each family member requesting continuing care coverage by a non-participating provider. Please note: Make sure the form is legible. If it is not legible and we need to send the form back to you, it will only delay your determination of transitional care. Any resubmission must still be in by 20 days before the effective date of your new plan. Determination is based on the information provided by you in this application. If any information should change, any prior determination will become void and a new application should be submitted by the designated deadline. Approval of continuing care is limited to the services requested and directly related to the medical condition described in the application. Services unrelated, but performed by the same physician will not be covered. You should note that any services received on or after the plan effective date, and prior to a determination of Continuity of Care eligibility, will not be eligible for the Continuity of Care benefit level if the request is denied. If the request is approved, any services prior to the approval date will need to be reviewed for eligibility. If you have enrolled in a plan with access to the Private Healthcare System (PHCS) network and if we are unable to approve the requested continuing care coverage, care provided by the non-participating provider, before or after denial, may be covered at the non-participating provider benefit level, if such level exists in your plan, subject to all applicable plan limitations. If you have enrolled in a plan which has an HMO level only and if we are unable to approve the requested continuing care coverage, care provided by the non-participating provider will not be covered at any level. If we approve the requested coverage, you must transition your care to a participating Kaiser Permanente physician by the end of the authorized time period. Failure to transition care to a participating Kaiser Permanente physician by the end of the authorized time period will result in non-payment by Kaiser Permanente of any outstanding and future claims by the non-participating provider. If you have enrolled in a plan which has an HMO level of coverage for continuity of care and if we are able to approve the requested continuing care coverage, Kaiser Permanente will attempt to reach financial agreement with your current Continuity of Care Page 1 Rev. 11/14/15

2 nonparticipating provider. Should negotiations not be successful, Kaiser Permanente will pay a maximum of Usual and Customary Rates (UCR). Any charges billed by your current non-participating provider above and beyond UCR, as described in the policy, will be your financial responsibility, in addition to any co-payments, co-insurance and/or deductibles required by the new Plan you have enrolled in. If you have any questions regarding the completion or status of this application, please call Section I (please print) Subscriber s Name: HRN/SS Number: Patient s Name: HRN/SS Number Daytime Number: Home Number: Patient s Address: City/State: Zip Employer s Name and Address: City/State: Zip: Plan Effective Date: Plan type enrolling in: Current Primary Care/Attending Physician: Phone Number: Section II (To be completed by applicant) Please check all that apply: Are you currently pregnant? Yes [ ] No [ ] Due Date: Have you been told that your pregnancy is moderate or high risk? Yes [ ] No [ ] Are you receiving radiation therapy, chemotherapy or other non-surgical treatment for cancer? Yes [ ] No [ ] Have you seen or are scheduled to see any of the following specialists: o Heart Specialists Continuity of Care Page 2 Rev. 11/14/15

3 o Surgeon o Mental Health Professional o Other Do you have insurance under any other plan that would cover this service? Yes [ ] No [ ] What is your other plan name and your member ID number? Authorization: I am requesting coverage for continuing care by the provider named above from Kaiser Permanente/KPIC for treatment that began prior to the Plan effective date. By signing below, I understand the following: If approved, the coverage for continuing care specified in this application will be covered for a limited time period. If approved, and I am enrolled in a plan which has an HMO level only, I will need to transition my care to a Kaiser Permanente physician by the time my continued care period has expired. Failure to transition care to a participating Kaiser Permanente physician by the end of the authorized time period will result in non-payment by Kaiser Permanente of any outstanding and future claims by the non-participating provider. If approved, and I am enrolled in a plan with access to the PHCS network, I understand it is my responsibility to confirm current network status with my current provider. Depending on the plan type I am enrolled in, approval/denial of this application may vary, including the length of time I am approved for. If any part of this application is not legible it will be returned, unprocessed, to me. Resubmission must still be by the designated deadline of 20 days prior to my new plan effective date. Determination is based on the information provided by me in this application. Should any information change, any prior determination will become void and a new application should be submitted by the designated deadline of 20 days prior to my new plan effective date. Approval of continuing care is limited to the services requested and directly related to the medical condition described in the application. Services unrelated, but performed by the same physician will not be covered. If approved, and I am enrolled in a plan with an HMO level of coverage for continuity of care, the maximum amount of charges that Kaiser Permanente will be liable for is equal to UCR for the services approved. Any charges billed by my current nonparticipating provider above and beyond UCR as described in the policy, will be my financial responsibility, in addition to any copayment, co-insurance and/or deductibles required by the level at which I am being covered under Continuity of Care. If approved, and I am enrolled in a plan with access to the PHCS network, the maximum amount of charges that KPIC will be liable for is equal to UCR for the services approved. Any charges billed by my current non-participating provider above and beyond UCR, will be my financial responsibility, in addition to any co-payment, co-insurance and/or deductibles required by the level at which I am being covered under Continuity of Care. If approved, deductibles and Out-of-pocket Maximums (OPM) will not cross accumulate between levels of coverage. The level of coverage I am receiving for continuity of care is the level in which my accumulators will be applied. I authorize all physicians and health care professionals to provide Kaiser Permanente/KPIC, with the medical information or records concerning care, treatment and advice for the conditions listed above, which will be used to determine the patient s eligibility for transition of care. Patient Signature: (18 years and older) Date: Parent Signature: (less than 18 years) Date: Continuity of Care Page 3 Rev. 11/14/15

4 Section III (To be completed by the physician or health care professional currently treating the above named condition) Please print: Physician Name: Specialty: Address: City/State: Zip: Office Phone Number: Date of last appointment: Next scheduled appointment: Diagnosis: Expected length of treatment: Frequency of visits: Obstetrics: Expected date of delivery: Is the treatment of the condition a result of an auto accident, worker s compensation, previous injury or chronic condition? Yes [ ] No [ ] If yes, please describe: Comments: ( please attach appropriate records if necessary) Continuity of Care Page 4 Rev. 11/14/15

5 Note: By signing below, I agree to continue treatment for the approved services and further understand that in the event I agree to the reimbursement level and contractual terms and conditions of the provider contract that I will not balance bill the patient for amounts over the contracted rate. Physician signature: Date: Section IV: for internal use only. To be filled out by Kaiser Permanente/KPIC Kaiser Permanente/KPIC representative: Approved: [ ] Not approved: [ ] Comments: Date: Continuity of Care Page 5 Rev. 11/14/15