Cigna Transition of Care and Continuity of Care Request Form
This form should be used to request Transition of Care or Continuity of Care for behavioral health conditions. It can be completed by the patient or their health care provider and requires a patient signature. Claims will be paid at the in-network level for the TOC/COC period only.
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How do I fill this out?
To fill out the Cigna TOC/COC Request Form, you will need to provide detailed information about the patient, health care provider, and the services requested. Ensure all required fields are completed accurately. Follow the submission instructions provided for mail or fax.
How to fill out the Cigna Transition of Care and Continuity of Care Request Form?
1
Check the appropriate box for the patient's status.
2
Fill out employer and patient information accurately.
3
Answer the series of questions about the patient's current treatments.
4
Complete the health care provider information with relevant details.
5
Sign the form and submit it via mail or fax as indicated.
Who needs the Cigna Transition of Care and Continuity of Care Request Form?
1
New enrollees in Cigna's network needing Transition of Care.
2
Patients whose health care provider has terminated needing Continuity of Care.
3
Patients notified by their employer that they may qualify for Continuity of Care.
4
Patients currently receiving routine outpatient therapy requiring an authorization.
5
Patients under medication management services needing a smooth care transition.
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What are the instructions for submitting this form?
Complete the Cigna TOC/COC Request Form by filling in all required fields accurately. Submit the form by mail to Evernorth Health Services, Attn: Outpatient Clinical Support Team, 6625 West 78th Street, Suite 100, Bloomington, MN 55439. Alternatively, fax the form to 844.271.1507. Ensure to follow the guidelines for timely submission and proper processing.
What are the important dates for this form in 2024 and 2025?
The Cigna TOC/COC Request Form is valid through January 2024 and must be submitted according to your healthcare plan's guidelines. Ensure form submission for timely processing and coverage continuity.
What is the purpose of this form?
The Cigna Transition of Care/Continuity of Care (TOC/COC) Request Form is designed to facilitate seamless healthcare service transitions for patients experiencing changes in their care providers or requiring ongoing behavioral health services. It ensures that patients continue receiving necessary treatments without interruption, even if their existing healthcare provider is no longer available or they have enrolled in a new health plan. Completing this form accurately and timely submission helps maintain continuity of care and prevents any gaps in treatment. Whether for mental health, substance use therapy, or other behavioral health services, the form makes sure that patients receive the appropriate in-network coverage for the TOC/COC period.
Tell me about this form and its components and fields line-by-line.
- 1. Employer Information: Includes employer's name, employee's details, policy number, member ID, and contact information.
- 2. Patient Information: Contains patient’s name, social security number or alternative ID, date of birth, and relationship to the employee.
- 3. Provider Information: Requires details about the healthcare provider, including group practice name, TIN, license type, service location, and contact information.
- 4. Treatment Information: Covers diagnostic codes, CPT codes, treatment start date, and requested authorization start date.
- 5. Authorization: Includes the signature of the patient or their guardian and the date.
What happens if I fail to submit this form?
Failure to submit the Cigna TOC/COC Request Form may result in denied claims or lack of coverage for necessary treatments. It's crucial to complete and submit the form on time to ensure continuous care.
- Denied Claims: Claims may be denied if the form is not submitted, leading to out-of-pocket expenses.
- Interrupted Care: Patients might face interruptions in their treatment without proper authorization for continued care.
How do I know when to use this form?
- 1. New Enrollees: Use this form if you are a new enrollee in Cigna’s network requiring transition of care.
- 2. Terminated Providers: Submit this form if your healthcare provider has terminated their services and you need continuity of care.
- 3. Employer Notification: Complete this form if your employer has notified you that you may qualify for continuity of care.
- 4. Current Treatments: Use this form if you are currently receiving treatments like outpatient therapy or medication management needing authorization.
- 5. Service Transition: Submit this form to ensure a seamless transition of your healthcare services without any interruptions.
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