Fillable Transition Coverage Request ECHS Category - TCRF (City of West Memphis)

Fill Online, Printable, Fillable, Blank Transition Coverage Request ECHS Category - TCRF (City of West Memphis) Form

Use Fill to complete blank online CITY OF WEST MEMPHIS (AR) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Transition Coverage Request ECHS Category - TCRF (City of West Memphis)

On average this form takes 18 minutes to complete

The Transition Coverage Request ECHS Category - TCRF (City of West Memphis) form is 5 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of West Memphis

BROWSE CITY OF WEST MEMPHIS (AR) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Transition Coverage Request ECHS Category - TCRF
Personal and confidential
Fully insured commercial members in California should not use this form
Here’s the form you requested for transition-of-care coverage from Aetna. If we approve your request, Aetna will cover
ongoing care at the highest level of benefits from
• An out-of-network doctor
• A doctor whose network status has changed
• Certain other health care providers who have treated you
Once we review your completed form, we’ll send you a letter explaining our decision.
Some things you should know about transition-of-care coverage
You’ll find answers to commonly asked questions about transition-of-care coverage on the other side of this form.
You should read them before filling out this form.
Transition-of-care coverage does not apply if your provider is in Aetna’s network (participating) or is part of your plan’s highest
benefit tier. Our DocFind
®
online provider directory is at www.aetna.com. It can tell you if your doctor is in the network or help
you find a participating provider for your Aetna plan. You can also call us at the phone number on your Aetna ID card.
How to complete the form and get it to us
Step 1: Fill out these sections:
1. Section 1 (Group or employer information).
2. Section 2 (Subscriber and patient information): Aetna plan information is on the front of the Aetna ID card.
3. Section 3 (Authorization): Read the authorization, then sign and date the form.
Step 2: Give the form to the doctor/health care provider to complete Section 4, including the diagnostic and treatment
information requested on page 4.
Step 3: Fax the completed form to Aetna for review. You should complete one form for each health care provider.
Fax medical and mental health/substance abuse requests to 1-859-455-8650
Be sure to complete all fields on pages 3 and 4. Your request will be answered faster that way.
GC-1395 (8-15) E R-POD
Aetna transition-of-care coverage questions and answers
Q. What is transition-of-care (TOC) coverage?
A. TOC coverage is temporary. You can get TOC when you become a new member of an Aetna medical benefits plan or change your Aetna plan,
and you are being treated by a doctor who:
• Is not in the Aetna network
• Is not included in Aexcel, tier 1 (for tiered network plans) or plan sponsor specific networks, and your benefits change to include one of
these networks
TOC coverage can also apply when your doctor leaves the Aetna network or changes network status or if certain laws or regulations require
coverage. Approved TOC coverage allows a member who is receiving treatment to continue the treatment for a limited time at the highest
plan benefits level.
TOC coverage is only for the requested doctor. Except in New York, TOC coverage does not include health care facilities, durable medical
equipment (DME) vendors or pharmaceutical items. If we approve TOC coverage, the doctor must use a health care facility, DME vendor or
pharmacy vendor in the Aetna network. If you want to request coverage for a vendor or facility outside the Aetna network, call the Member
Services phone number on your Aetna ID card.
Q. What is an active course of treatment?
A. An active course of treatment means 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 active course-of-treatment examples may include, but are not limited to members who:
• Enroll with Aetna after 20 weeks of pregnancy, unless there are specific state or plan requirements (Members less than 20 weeks pregnant
whom Aetna confirms as high risk are reviewed on a case-by-case basis.)
• Have completed 14 weeks of pregnancy or more and are receiving care from an Aetna participating practitioner whose network status
changes.
• Are in an ongoing treatment plan, such as chemotherapy or radiation therapy.
• Have a terminal illness and are expected to live six months or less.
• Need more than one surgery, such as cleft palate repair.
• Have recently had surgery.
• Are being treated for a mental illness or for substance abuse. (The member must have had at least one treatment session within 30 days
before the status of the member or the participating health care provider changed.)
• Have an ongoing or disabling condition that suddenly gets worse.
• May need or have had an organ or bone marrow transplant.
To be considered for TOC coverage, treatment must have started before the enrollment or re-enrollment date, or before the date your doctor
left the Aetna network, or before the date a doctor’s network status changed.
Q. What other types of providers, besides doctors, can be considered for TOC coverage?
A. This includes health care professionals such as physical therapists, occupational therapists, speech therapists and agencies that provide skilled
home care services, such as visiting nurses. TOC is considered for participating hospitals only when the facility is not designated for the highest
benefit level for plans that include tiered networks. TOC does not apply to other health care facilities (for example, skilled nursing facility), DME
vendors or pharmaceutical items.
Q. If I am currently receiving treatment from my doctor, why wouldn’t you approve my request for TOC coverage?
A. If you’re receiving treatment, the procedure or service must be a covered benefit. Your doctor must also agree to accept the terms outlined on
the TOC request form.
Q. My PCP is no longer an Aetna provider. If my plan requires me to select a PCP, can I still see my doctor?
A. If you’re receiving treatment, you may still be able to visit your PCP, even if he/she leaves the network. In all states, except Texas and New
Jersey, you may need to select a PCP in the Aetna network. In Texas and New Jersey, TOC may apply to PCPs. Talk to your PCP so that
he/she can help you with your future health care needs.
Q. How long does TOC coverage last?
A. Usually, TOC coverage lasts 90 days, but this may vary based on your condition (for example, pregnancy). We will tell you if your TOC
coverage request is approved and how long the coverage will last.
Q. How do I sign up for TOC coverage?
A. Contact the Member Services number on your Aetna ID card. You must submit a TOC request form to Aetna:
• Within 90 days of when you enroll or re-enroll
• Within 90 days of the date the health care provider left the Aetna network
• Within 90 days of a doctor’s network status change
You or your doctor can send in the request form.
Q. How will I know if my request for TOC coverage is approved?
A. We will send you a letter via U.S. mail. The letter will say whether or not you are approved.
Q. Does TOC coverage apply to the Traditional Choice
®
or Medicare Advantage PPO ESA (extended service area) plans?
A. No.
Q. What if I have an Aexcel or plan sponsor specific network plan?
A. If we approve your TOC coverage, you may still receive care at the highest benefits level for a certain time period. If you continue treatment
with this doctor after the approved time period, your coverage would be limited to what your plan allows. This means you may have reduced
benefits or no benefits.
Q. What if I have more questions about TOC coverage?
A. Call the Member Services phone number on your Aetna ID card. If you have questions about TOC mental health services, you can call the
Member Services phone number on your ID card or, if listed, the mental health or behavioral health number.
GC-1395 (8-15) E
Transition Coverage Request ECHS Category - TCRF
Personal and confidential
Fully insured commercial members in California should not use this form
Medical Mental health/substance abuse
Please indicate above whether this request is for medical treatment or mental health/substance abuse treatment.
1. Group or employer information (Note: Complete a separate form for each member and/or provider.)
Group or employer’s name (please print)
Plan control number
Plan effective date (required)
2. Subscriber and patient information
Subscriber’s name (please print)
Subscriber’s Aetna ID number
Subscriber’s address (please print)
Patient’s name (please print)
Birthdate (MM/DD/YYYY)
Patient’s address (please print)
Telephone number
Plan type/product
Telephone number for patient/subscriber submitting request (Business hours, 9 a.m. – 5 p.m.)
Last date of treatment before beginning Aetna coverage (as applicable)
3. Authorization
I request approval for coverage of ongoing care from the health care 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, or before the provider’s network status change. If
approved, I understand that the authorization for coverage of services stated below will be valid for a certain period of time. 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 age 17 or older)
Date (MM/DD/YYYY)
Parent’s signature (required if patient is age 16 or younger)
Date (MM/DD/YYYY)
4. Provider information (Note: Provide all specific information to avoid delay in the processing of this request.)
Name of treating doctor or other health care provider (Please print)
Telephone number
Contact name of office personnel to call with questions
Address of treating doctor or other health care provider (Please print)
Tax ID number
Signature of treating doctor or other health care provider
Date (MM/DD/YYYY)
The above-named patient is an Aetna member as of the effective date indicated above. We understand you are not or soon
will not be a participating provider in the Aetna network. The patient has asked that we cover your care for a specific time
period. This is because of a condition, such as pregnancy, that is considered an active course of treatment. 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 patient’s current condition and treatment plan. For pregnancies, please
indicate the estimated date of confinement (EDC). If we approve this request, you agree:
• To provide the patient’s treatment and follow-up
• Not to seek more payment from this patient other than the patient responsibility under the patient’s plan of benefits
(for example, patient’s copayment, deductibles or other out-of-pocket requirements)
• To share information on the patient’s treatment with us
You also agree to use the Aetna network for any referrals, lab work or hospitalizations for services not part of the requested
treatment. In New York state, the provider completing the form may not be leaving the network, but may request continuing
care to be provided by a hospital that is leaving the network.
GC-1395 (8-15) E
This page intentionally left blank.
GC-1395 (8-15) E
Transition Coverage Request ECHS Category - TCRF
Personal and confidential
Fully insured commercial members in California should not use this form
Patient’s name (please print)
Birthdate (MM/DD/YYYY)
Provider: Please complete the diagnostic and treatment information below describing the active course of treatment.
Description of all medical and
behavioral health-related diagnoses
(for example, pregnancy, cancer,
depression, post-operative). Include
all ICD codes:
Description of all treatment and
procedures. Include all CPT codes:
Date of
original
surgery, if
applicable:
Date care
was initiated:
Dates of current
treatment:
(Please provide
copies of medical
records from the last
office visit.)
Number of additional
visits needed :
(For pregnancy, please
include EDC.)
GC-1395 (8-15) E
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 Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
Attention Arkansas, District of Columbia, 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 a
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.
Attention Louisiana 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 is guilty of a crime and may be subject to fines and confinement in prison. 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 or willfully presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly or 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 Missouri 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, denial of insurance and civil damages, as determined
by a court of law. Any person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as
determined by a court of law.
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, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement 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 Texas 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 intentional misrepresentation of material fact or conceals, for
the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime
and may subject such person to criminal and civil penalties.
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 (8-15) E
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Transition Coverage Request ECHS Category - TCRF (City of West Memphis)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document