Transitional Care Benefits Request Form
This form is used by members of Blue Cross Blue Shield of Texas to request transitional care benefits. It helps in coordinating medical care with a new plan. Transitional care benefits may be available for up to 90 days after the group's effective date of coverage.
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How do I fill this out?
Filling out this form is essential to request transitional care benefits. Follow the steps to provide accurate information about your medical condition and provider details. Ensure all fields are completed before submission.
How to fill out the Transitional Care Benefits Request Form?
1
Provide group name, group number, and employee name.
2
Enter patient information including ID, name, birth date, and contact details.
3
Answer questions related to the patient's health condition, pregnancy, surgery, or transplant list.
4
Provide physician or provider's information, including name, address, and contact details.
5
Sign and date the authorization section and submit the form via mail or fax.
Who needs the Transitional Care Benefits Request Form?
1
Members transitioning to a new medical plan who need assistance with ongoing medical care.
2
Patients currently under treatment by out-of-network physicians.
3
Pregnant women who are receiving care from out-of-network providers.
4
Patients with scheduled surgeries or recent surgeries.
5
Individuals on a transplant list needing ongoing care coordination.
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Fill out the required information in each field.
3
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What are the instructions for submitting this form?
Submit the completed form by fax to 866-739-4093 or by mail to Blue Cross and Blue Shield of Texas, Utilization Management - Transitional Benefits, P.O. Box 833874, Richardson, TX 75083-3874. Include all required information and ensure the form is signed and dated. It is advisable to keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
The transitional care benefits may be available for up to 90 days after your group's effective date of coverage. After 90 days, the medical director will review any requests for benefits made in writing according to the standard prior authorization review process.
What is the purpose of this form?
The purpose of this form is to assist members of Blue Cross Blue Shield of Texas in requesting transitional care benefits. It is especially useful for those who are currently receiving medical treatment from out-of-network physicians. The form facilitates the coordination of medical care with the new medical plan and ensures continuity of care.
Tell me about this form and its components and fields line-by-line.
- 1. Group Name: Name of the group or organization providing the health plan.
- 2. Group Number: Unique identification number assigned to the health plan group.
- 3. Employee Name: Name of the employee covered under the health plan.
- 4. ID# / SS#: Identification number or Social Security number of the patient.
- 5. Patient Information: Includes name, birth date, address, and contact information of the patient.
- 6. Medical Information: Details about the patient's health condition, diagnosis, treatment plan, pregnancy status, surgery, and transplant list.
- 7. Physician or Provider Information: Details about the healthcare providers, including names, addresses, and contact information.
- 8. Sign and Date: Signature of the patient or guardian and the date of signing.
- 9. Return Form to: Instructions for submitting the form, including mail and fax details.
What happens if I fail to submit this form?
If you fail to submit this form, you may not be eligible for transitional care benefits.
- Denial of Benefits: You may not receive the benefits you are entitled to under your health plan.
- Interruption in Care: Your ongoing medical treatment may be disrupted due to lack of coordination with new providers.
How do I know when to use this form?
- 1. Transitioning Plans: Use when moving to a new health plan and need to coordinate ongoing care.
- 2. Out-of-Network Treatment: Use when currently receiving care from providers not listed in the provider directory.
- 3. Pregnancy Care: Use when receiving care for a pregnancy from out-of-network providers.
- 4. Scheduled Surgery: Use when you have a scheduled surgery or recently underwent surgery.
- 5. Transplant List: Use when you are on a transplant list and need continuity of care.
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What information do I need to provide on the form?
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