Certain events can cause your benefits and coverage to change. In some cases, you may need to request transition of care services. Transition of care services are available when you move from one doctor to another.
If you are a new HMO plan member or your doctor is no longer in your network, you may request transition of care services.
If you are a new member, you must request transition of care services within 15 days of when your coverage began. For existing members, you must request transition of care services within 30 business days after receiving notice that your doctor is no longer with your medical group.
If you are in one of these situations and are receiving frequent or ongoing care for a medical condition or pregnancy beyond the first trimester, you can request that you be allowed to continue with your current specialists for a period of time. You may call the HMO customer assistance unit (CAU) at 312-653-6600 for help.
Transition of Care from Pediatric to Adult Care
When you have a child who reaches adult age or is a pregnant adolescent, your pediatrician may request that your child change to a primary care provider (PCP) who specializes in internal medicine or family medicine. This ensures that your child will be taken care of by a doctor who has experience in providing care for adults. Your medical group can help you choose a doctor.
Limited Benefit Used Up
Some benefit plans have limited benefits for outpatient rehabilitation therapies. Once you have used up a limited benefit, your medical group will document this in writing to you within two business days. The document will include:
- The fact that benefits are exhausted
- Your doctor’s name
- Your appeal rights and procedures
- A reminder that the charges incurred beyond the contract limits are your financial responsibility
- Information about your options for continuing care and ways to obtain further care as appropriate.