OMAP - Medical Assistance Bulletin Number 99-03-13, attachment D

REQUIREMENTS: - Immediately: Billing team must update claims processing workflows to recognize and honor continuity-of-care transition periods when members enroll in new MCOs or switch from FFS/MCO delivery systems. - Establish policy in billing system: Do NOT deny or require prior authorization for ongoing courses of treatment during the 60-day continuity-of-care transition period, even if services are from non-participating network providers. - Add verification step: Before processing claims for members with recent enrollment changes, verify with previous provider/delivery system whether member is receiving an ongoing course of treatment that qualifies for continuity protections. - For OB-GYN cases: Flag that pregnant members and postpartum cases receive extended continuity (throughout pregnancy and postpartum period related to delivery), not just 60 days—ensure billing system accommodates extended coverage periods. - Update denial procedures: If concurrent clinical review after 60 days results in treatment modification/denial for adults age 21+, billing team must ensure proper written notice is issued and claims must continue to be processed if grievance/fair hearing is filed within 10 days (services continue pending decision). - Train billing staff: Ensure team understands that MCOs cannot deny coverage for services provided during continuity-of-care periods under same terms as participating providers, and that continuity applies to children under 21 indefinitely if services require prior auth under new system. - Coordination with providers: Establish internal protocol to request approval/prior authorization information from previous providers when member transitions, as this information must be conveyed to new providers per policy.