Transition Coverage Request
Personal & Confidential
(See reversed side for Transition of Care Coverage Questions and Answers)
This is a formal request for Aetna to cover ongoing care at the preferred or the highest level of benefit from:
• An out-of-network doctor;
• Certain other healthcare providers from whom you have been receiving treatment.
You will receive a coverage decision by mail. If the coverage is not approved, care by the selected provider will not be
covered after the plan’s effective date, or after the end of the provider’s contract with the Aetna network, or will be covered at
the non-preferred rate or the lowest in-network rate.
MEMBER: Please complete:
1. Section 1 (Employer Information)
2. Section 2 (Employee and Member Information — this is on the front of the ID card)
3. Section 3 (Authorization) Read the authorization, sign and date the form (if patient is age 17 or older, he or she must
also sign and date this form).
THEN — Give the form to the doctor to complete Section 4 (Doctor Information).
After your doctor fills out Section 4, then fax the completed form to SRC, An Aetna Company for review at 1-859-455-8650.
1. Employer Information
Employer’s Name (Please print)
Group Number
Plan Effective Date (Required)
2. Employee and Member Information
Employee Name (Please print)
Employee Social Security Number (or Aetna Identification Number)
Employee Address (Please print)
Birthdate (MM/DD/YYYY)
Member’s Name (Please print)
Telephone Number
3. Authorization
I request approval for coverage of ongoing care from the healthcare provider named below for treatment started before my
effective date with Aetna, or before the end of the provider’s contract with the Aetna network. If approved, I understand that
the authorization for coverage of services stated below will be valid for a certain limited period of time. I further understand
coverage will be subject to the benefits, exclusions, limits, and maximums of the new plan. I give permission for the health
care provider to send any needed medical information and/or records to Aetna so a decision can be made.
Patient’s Signature (Required if Patient is 17 or Older)
Date (MM/DD/YYYY)
Parent’s Signature (Required if Patient is 16 or Younger)
Date (MM/DD/YYYY)
4. Doctor Information - Please provide all specific information to avoid delay in the processing of this request.
Name of Treating Doctor or other healthcare provider (Please print)
Telephone Number
Address of Treating Doctor or other healthcare provider (Please print)
Date (MM/DD/YYYY)
Signature of Treating Doctor other healthcare provider
The above named patient is currently an Aetna member as of the effective date indicated above. Although you are not or
soon will not be a participating provider in the Plan network, the member has requested that we cover care provided by you
for a specific period of time because of a condition requiring an active course of treatment (for example, pregnancy). An
active course of treatment is defined as: “A program of planned services starting on the date the provider first renders a
service to correct or treat the diagnosed condition and covering a defined number of services or period of treatment and
includes a qualifying situation”. Please include a brief statement of the member’s current condition and treatment plan. For
pregnancies, please indicate the estimated date of confinement (EDC). In the event this request is approved, you agree to
provide the member’s treatment and follow-up; to not seek payment from the member for any amount the member would not
be responsible for if you were a participating provider; to share information regarding the treatment plan with Aetna; and, to
use the Aetna provider network for any necessary referrals, lab work or hospitalizations.
Please list diagnosis, specific treatment, start date of treatment, and dates of current or future treatment.
Diagnosis (including ICD-9 codes)
Treatment (include related codes)
Start Date of Treatment
Dates of Current and Anticipated Treatment
1.
2.
MDRSTOC
GC-1395-4 (6-10)
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Aetna Transition of Care Coverage Questions and Answers
Q. What is Transition of Care (TOC) coverage?
A. TOC coverage is temporary coverage when you become a new member of an Aetna medical benefit plan or change your current Aetna medical plan,
and a doctor you are being treated by:
• Is not in the Aetna network or;
• Leaves the Aetna network.
TOC coverage is not for Primary Care Physicians (PCPs) who are not in the Aetna network, except when the PCP leaves the Aetna network during your
plan year, and you are receiving treatment, or if certain laws or regulations apply. TOC coverage allows a member who is receiving treatment to
continue the treatment for a limited time at the preferred plan benefit level. Approval of TOC requests are subject to the terms and limits of your plan.
TOC coverage is only for the requested doctor and does not include facilities or hospitals. If the request is approved, the doctor must use a facility or
hospital in the Aetna network.
Q What is an active course of treatment?
A. An active course of treatment is when you have begun a program of planned services with your doctor to correct or treat a diagnosed condition. The
start date is the first date of service or treatment. An active course of treatment covers a certain number of services or period of treatment for special
situations. Some examples may include, but are not limited to:
• Members enrolling with Aetna beyond 24 weeks of pregnancy (unless there are specific state or plan requirements). Members less than 24
weeks pregnant whom Aetna confirms as high risk are reviewed on a case-by-case basis.
• Members in an ongoing treatment plan, such as chemotherapy or radiation therapy;
• Members with a terminal illness, expected to live six months or less;
• Members who need more than one surgery, such as cleft palate repair;
• Members who have recently had surgery;
• Members who receive outpatient treatment for a mental illness or for substance abuse. (The member must have had at least one [1] treatment
session within 30 days before the effective/renewal date of the Aetna plan).
• Members with an ongoing or disabling condition that suddenly gets worse;
• Members who may need or have had an organ or bone marrow transplant.
To be considered for TOC coverage, the course of treatment must have started before the enrollment or re-enrollment date or before the date your
doctor left the Aetna network.
Q. What other types of providers, besides doctors, can be considered for TOC coverage?
A. Health care professionals such as physical therapists, occupational therapists, speech therapists, and agencies that provide skilled home care services
such as visiting nurses. TOC does not apply to durable medical equipment (DME) vendors, health care facilities (e.g. hospital, skilled nursing facility) or
pharmacy vendors.
Q. If I am currently receiving treatment from my doctor, why wouldn’t my request be approved for TOC coverage?
A. In addition to currently receiving treatment, your request must involve a covered procedure/service. Your doctor must also agree to accept the terms
outlined on the TOC Request Form.
Q. How long does TOC coverage last?
A. Usually, TOC coverage lasts 90 days. You will be informed if your TOC coverage request is approved and how long it will last.
Q. How do I sign up for TOC coverage?
A. Contact Member Services. A TOC Request Form must be submitted to SRC:
• Within ninety (90) days of when you enroll or re-enroll; or
• Within 90 days of the date, the provider left the Aetna network.
To get the highest level of benefit coverage, newly enrolling and re-enrolling members must be approved before receiving further services. You or your
doctor can send in the request form.
Q. How will I know if my request for TOC coverage is approved?
A. You will receive a letter in the mail. The letter will say whether or not you are approved. If you are approved, any treatments you received before the
approval date will not be covered at the highest benefit level, unless there was an emergency.
Q. I am going to receive services after the start date of my Aetna plan. The doctor is part of the Aetna network. Will the services be covered under my Aetna plan?
A. Please ask your doctor to confirm if approval is needed. If so, you can request approval by filling out a TOC form.
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Misrepresentation
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and civil penalties.
Attention Arkansas, District of Columbia, Louisiana, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison. Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado
Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas
Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have
violated state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties. Attention Maine and Tennessee
Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly and willfully presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an
insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention New York
Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance
act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Attention North
Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who knowingly and
with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or
conceals, for the purpose of misleading, information concerning any fact material thereto is guilty of insurance fraud. Attention Oklahoma Residents: WARNING:
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance
company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with
intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals,
for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application
for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or
damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand
dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five
(5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Vermont Residents: Any person who
knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may
be a crime and may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or
deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil
penalties. Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
GC-1395-4 (6-10)
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