WHAT IS TRANSITION OF CARE - Marquette University



WHAT IS TRANSITION OF CARE?

In-network benefit levels may apply to medical care by physicians or providers who are not network participants, for a limited period of time, on an exception basis. Exceptions will be considered ONLY for the rare situations listed below. The provider must be participating in the network under your prior medical benefit plan in order to be eligible for this consideration.

Transition of Care must be requested as early as possible but no later than January 1, 2009. Special situations may include:

HOSPITALIZATION

Coverage for a member hospitalized prior to January 1, 2009 and remaining hospitalized after January 1, 2009. Upon discharge from the hospital, there may be a need for Transition of Care for services provided after January 1, 2009 if the hospital is not in the network. A member will have 30 days from the date of discharge to complete a Transition of Care Request form and submit it to Aurora Medical Management.

PREGNANCY

A member who is in her third trimester (week 28 to 40) and wishes to continue with a physician not in the Aurora Direct Network should request a Transition of Care. Members who are pregnant but are in their first trimester (week 1 to 13), or second trimester (week 14 to 27) is expected to be able to safely transition to a provider within the Aurora Direct Network. However a patient in her first or second trimester with certain high-risk indicators may be eligible for Transition of Care and should complete the form noting this information.

SERIOUS MEDICAL CONDITION

A member requiring ongoing follow-up care for a SERIOUS medical condition (E.G., follow-up care for surgery performed just prior to January 1, 2009, cancer care, dialysis, transplants,) should request Transition of Care. If approved, coverage at the in-network level of benefits may be continued for up to 90 days.

PSYCHIATRIC/SUBSTANCE ABUSE

A member who is in treatment prior to January 1, 2009 with a provider not in the network and who is expected to complete treatment within 90 days should request a Transition of Care for services provided after January 1, 2009. For behavioral health you may call at 800-647-6529 or complete and mail the attached behavioral health Transition of Care form. If approved, coverage at the in-network level many be continued for up to 90 days only.

A Transition of Care Request Form, when completed will provide information necessary to evaluate whether or not an exception is medically necessary. Any member who believes they meet the above criteria and wants to be evaluated for a possible exception must complete the form if he or she wishes to continue the current care at the in-network level of benefits under this exception. You will be notified of the approval or denial of your request. If you have any questions or need clarification regarding Medical Transitions of Care please send an email to patricia.hamann@ prior to January 1, 2009.

|MEDICAL completed Transition of Care form should be mailed or faxed to: |

|Aurora Health Care Attn: Medical Management Team |

|P.O. Box 196. Elm Grove, WI 53122-0196 |

|FAX: 262-787-2800 |

| |

|The deadline for submission is December 31, 2008. |

If you have any questions or need clarification regarding Behavioral Health Transitions of Care please send an email to Janet.schirtzinger@ prior to January 1, 2009

BEHAVIORAL HEALTH completed Transition of Care forms should be mailed or faxed:

Aurora Health Care – Attn: Behavioral Health Management Team

4067 North 92nd Street

Wauwatosa, WI 53222

FAX: 414-760-5418

The deadline for submission is December 31, 2008.

Transition of Care Request Form

Date: Employee Social Security Number:

Employee Name:

Last First MI

Employee Address:

Street City State Zip

Employer:

Patient Name:

Last First MI

Home Phone: Work Phone:

Scheduled Surgery:

Hospital or Surgery Facility:

Procedure:

Surgeon: Office Phone:

Date Procedure Scheduled:

Pregnancy:

Expected Delivery Date: Hospital:

Obstetrician Managing Pregnancy: Office Phone:

Date of first office visit: Date of most recent office visit: Date of next scheduled office visit:

Estimated duration of care for this transition:

Other Serious Medical Problem (e.g., chemotherapy, dialysis, transplants):

Diagnosis:

Physician managing care: Office Phone:

Date started: Medication/Procedure:

Length of time above doctor has been managing care:

Dates of first most recent office visit: Estimated duration of care for this transition:

Current Behavioral Health Care:

Provider Name and Credential:

Clinic Name:

Clinic Address: Clinic City:

Office Phone: Estimated duration of care for this transition:

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