Continuity of care

This information addresses a wide range of questions about continuity of care for members enrolled in a WellFirst Health – Provided by SSM Health Plan – benefit plan.

With continuity of care, you may be able to receive services at in-network coverage levels in certain circumstances when your health care provider leaves your plan’s network. Continued coverage is for a defined time period, and is dependent on whether the provider is available and agrees to continue your care.

Note: We cannot guarantee that your provider will agree or be in a position to continue your care. You must contact your current provider to see if they are able to continue care at their new location for your continuity of care time period.
Members who are actively receiving services from a provider who has or is leaving your plan’s network may be eligible for continuity of care. Continuity of care acts as a bridge until you are able to establish a new provider within the plan’s network or through the continuity of care end date, whichever comes first.

Eligible members will receive a letter from the health plan explaining this process.
The health plan determines continuity of care eligibility based on member claims information. If the provider is not your primary care provider or a specialist you are seeing for ongoing care, disregard the letter.
Continuity of care is provided to allow for a safe transition of care to another provided who is covered under your plan. Specific timeframes are determined by applicable state and federal laws; refer to your letter for your allotted continuity of care timeframe.
No, it is your choice on whether to choose continuity of care. The purpose of continuity of care is to allow you time to choose another provider who is covered under your plan without interrupting your existing care. If you can do this comfortably, you may decide to move to another provider who is covered under your plan without choosing continuity of care.
If you do not wish to choose continuity of care, you can work with your clinic location to select a new provider. Follow the steps below to be sure you are taking the needed actions for this option:

Step 1 Is the provider identified in your continuity of care letter your primary care provider?
  • If NO, move to step 2.
  • If YES, are you enrolled in a Medicare Advantage Plan or State of Wisconsin Employee Trust Fund plan?
    • If NO, move to step 2.
    • If YES, in most cases a new primary care provider is automatically assigned to members enrolled in a Medicare Advantage or State of Wisconsin Employee Trust Fund plan. If you are unsure if a new primary care provider has been automatically assigned to you — or if you wish to select your own primary care provider, contact the Customer Care Center. You don't need to complete any of the additional steps.

Step 2. Was a prior authorization needed for you to go to this location or for your services? For example, did your provider need to have written approval before providing your care? If you are unsure, call our Customer Care Center.
  • If NO, you may find another provider at your clinic location in our provider directory. Call our Customer Care Center if you would like help finding another provider covered under your plan.
  • If YES, you must contact your clinic location, pick a new provider at that location and ask them to update and resubmit a prior authorization for your care.
We will offer continued in-network coverage if your provider also agrees to continue your care at their new location for the set period of time listed in your continuity of care letter. You must complete the steps below in order to choose your continuity of care. If you do not complete all of the steps, claims for your services with this provider at their new location may be denied and you could be held responsible for payment.

Step 1. Check with your current provider to see if they will continue care at their new location for your Continuity of Care time period. If they agree, move to Step 2. If they don’t agree, continuity of care isn’t an option because it depends on whether the provider can continue your care. However, you can move your care to another provider who is covered under your plan by talking with the same (in-network) location your current provider is at or calling our Customer Care Center to find a new provider

Step 2.  Ask your provider for the following information:
  • Address of their new location
  • Tax identification number (TIN)
  • Organizational NPI number, also referred to as NPI Type 2 number
Call our Customer Care Center if you need help.

Step 3. Contact the Customer Care Center and tell us you want to use your continuity of care. Share your provider’s new information with us when you call.
If you have completed all of the steps to enact continuity of care, it provides coverage of care subject to the terms of your plan.

Continuity of care will not cover out-of-network hospital charges. Out-of-network services require prior authorization. Call our Customer Care Center if you have questions.
There can be a number of reasons why a provider may not be able to continue a patient’s care once they are no longer part of the health plan’s provider network, such as a non-compete clause with their previous employer or the terms of their agreement with their new employer.

While we offer continuity of care coverage, we cannot guarantee your provider will still be able to see you. Your provider must also agree to continue your care at their new location in order for you to enact continuity of care.

If your provider is not able to continue your care, use our provider directory to see a list of available providers.
We understand that everyone’s situation is unique, and it is important to us that your care is not interrupted. Call our Customer Care Center to discuss your situation and options.
Yes, if the provider leaving the network is your primary care provider, in some cases a new primary care provider is automatically assigned.

If you are uncertain if a new primary care provider has been automatically assigned or if you wish to select your new primary care provider, contact the Customer Care Center.
Yes, in some cases a new member ID card will be issued. If you have not received a new member ID card and believe you should have, call the Customer Care Center.

Find a provider

See our provider directory to find a provider for your plan.


Questions?

Contact our Customer Care Center.