Transition of Care
Transition of care benefits may be available to you and/or your dependents as a member of a new plan joining during open enrollment.
Applying for Transition of Care
- BRMS must receive requests from members of new plans, who are joining during open enrollment, within the first 30 days after the effective date of coverage.
- Individuals must currently be receiving treatment for the condition by the provider identified on the transition of care request form.
- If transition of care benefits are approved, then the individual will receive the in-network level of benefits for treatment of the specific condition by the provider for a specified timeframe, The timeframe will be determined upon approval, and shall not exceed ninety (90) days.
- If the request for transition of care benefits has been approved, the transition of care benefits apply only to the treatment provided or ordered by the physician identified on the transition of care request form for the medical condition specified on the form.
- The availability of transition of care benefits is still subject to the terms of the benefit plan. For example, requests will be reviewed to determine whether the benefit is covered and whether it is medically necessary
- All benefits are subject to the provisions of the plan.
- BRMS will attempt to negotiate reasonable reimbursement rates with the provider on the member’s behalf. However, if rates are non-negotiable, reimbursement may be based on usual and customary (U&C)
Examples of acute medical conditions that may qualify for transition of care benefit include, but are not limited to:
- Pregnancy, in the third trimester of care.
- Solid organ transplants on a transplant list and anticipated to undergo transplant within 30 days.
- Bone marrow transplants who are less than six months post transplant.
- End-stage renal disease and dialysis.
- Terminal illness with an anticipated life expectancy of six months or less.
Examples of conditions that generally do not qualify for transition of care benefits include, but are not limited to:
- Routine exams, vaccinations, and health assessments.
- Stable chronic conditions such as diabetes, arthritis, allergies, asthmas, glaucoma, etc.
- Elective scheduled surgeries such as removal of lesions, arthroscopies, hernia repairs, hysterectomy, etc.
- Services for speech therapy, physical therapy and home health care.
Frequently Asked Questions:
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What timeframe is allowed for transitioning to a participating provider?
Upon approval of your request, you will be notified in writing of the number of days for which your transition of care benefits are approved, which is 90 days or less
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If I am approved for transition of care benefits for one illness, can I receive in-network benefits for a non-related condition?
In-network benefit levels provided in conjunction with transition of care are for the specific illness/condition only and cannot be applied to another illness/condition.
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Can I apply for transition of care benefits if I am not currently in treatment or seeing a physician?
Individuals must currently be receiving treatment for the condition by the physician that is noted on the transition of care form.
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Do I need to complete the Transition of Care Request Form if I am already seeing a participating provider?
No, you do not need to request transition of care if your provider is already participating in Sutter or Blue Cross’ network. To verify a provider’s status, Sutter physicians and facilities contact BRMS directly by calling the number on your member identification card.
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Folsom, CA 95630