Physicians Leaving the Network

Enrolling in GlobalHealth does not guarantee services by a particular provider listed in the Provider Directory. A provider may choose to leave our network.

Continuity of Care Provision

Current GlobalHealth members may keep getting care from their provider who is leaving the network in certain cases through the continuity of care provision.

Examples of conditions that may require continuity of care:

• Behavioral health conditions during active treatment
• Currently hospitalized
• Currently taking drugs for which we require prior authorization or step therapy review
• Currently on a transplant list
• Impending hospitalization
• Second or third trimester pregnancies
• Terminal illness
• Undergoing chemotherapy or radiation therapy.

Approval

You must get approval from us to continue care with an out-of-network provider.

You must be in active treatment. “Active treatment” means:

• Ongoing treatment for a life-threatening disease or condition;
• Ongoing treatment for a serious acute condition;
• The second or third trimester of pregnancy through the postpartum period; or
• Ongoing treatment for which a treating doctor or other provider attests that changing care to another doctor or provider would make the condition or expected outcome worse.

We will not approve the continuity of care provision in cases where:

• The provider's contract ended due to quality of care issues.
• The provider did not comply with regulatory or other contract requirements.

If we do not approve ongoing care through the out-of-network provider, you may appeal the decision.

Notice

We will tell you within 30 days of the date we find out that your provider has or will be leaving our network. If the provider is your PCP, we will send you a letter with the name of your new PCP. You will also get a new member ID card in a separate mailing. If you do not want the PCP we chose for you, let us know. If your provider is a specialist, the letter will tell you what the next steps are.

When the Provision Ends

These provisions end when you transfer to a network-provider, you reach benefit limitations, or care is excessive or not medically necessary.

Limitations

Provisions apply only to the condition and the provider shown on the request form. An in-network provider must treat all other conditions. If you need referral services, we may authorize for in-network providers only.

• If approved for continuity of care, we cover care for up to 90 days while we are working to transfer your care.
• If you are pregnant, we cover continuity care through six weeks postpartum, even if it is more than 90 days.
• If you remain enrolled in the same plan across plan years, these timeframes apply across plan years.
• Treatment for the condition must have been within the previous 30 days.

Appointment of Representative

Others that may help with this process include.

• Your doctor or pharmacist.
• The parent of a child under 18 years of age.
• Your power of attorney with medical decision authority. We must have a copy of the signed power of attorney form on file.
• Your authorized representative. You will need to complete the appointment of representative form if you want us to share your PHI with anyone else, for example:
  • Your parent, if you are age 18 or over.
  • Your spouse.
  • Your caregiver, friend, neighbor, or other.