Transition Coverage Request at a glance
What it is: Transition Coverage Request 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 or certain other healthcare providers.
Where and when to file: After the doctor fills out Section 4, fax the completed form to SRC, An Aetna Company for review at 1-859-455-8650.
A filled-in Transition Coverage Request example: an adult member requests transition coverage
How to fill out Transition Coverage Request, box by box
1. Employer Information
In 1. Employer Information, enter the Employer's Name (Please print), the Group Number and the Plan Effective Date (Required).
2. Employee and Member Information
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).
In 2. Employee and Member Information, enter the Employee Name (Please print), the Employee Social Security Number (or Aetna Identification Number) and the Employee Address (Please print).
Enter the Member's Name (Please print), the Birthdate (MM/DD/YYYY) and the Telephone Number.
3. Authorization
Section 3 (Authorization): I request approval for coverage of ongoing care from the healthcare provider named 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 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
Give the form to the doctor to complete Section 4 (Doctor Information).
In 4. Doctor Information, provide all specific information to avoid delay in the processing of this request.
Enter the Name of Treating Doctor or other healthcare provider (Please print), the Telephone Number and the Address of Treating Doctor or other healthcare provider (Please print).
Signature of Treating Doctor other healthcare provider.
Diagnosis and treatment
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 and Dates of Current and Anticipated Treatment.
More rules for Transition Coverage Request
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.
You will receive a letter in the mail. 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.
4. To get the highest level of benefit coverage, newly enrolling and re-enrolling members must be approved before receiving further services.
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. 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.
You or your doctor can send in the request form.
Usually, TOC coverage lasts 90 days.
You will be informed if your TOC coverage request is approved and how long it will last.
Common questions about Transition Coverage Request
Is there a deadline?
A TOC Request Form must be submitted to SRC within ninety (90) days of when you enroll or re-enroll (2); or within 90 days of the date, the provider left the Aetna network (3).
Where do I file it?
After the doctor fills out Section 4, fax the completed form to SRC, An Aetna Company for review at 1-859-455-8650.
Is there a penalty?
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.
When is this form not the right one?
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 is only for the requested doctor and does not include facilities or hospitals. TOC does not apply to durable medical equipment (DME) vendors, health care facilities (e.g. hospital, skilled nursing facility) or pharmacy vendors.
Sources
[1] Transition Coverage Request (6-10), Aetna (the Official source link on this page).