Summary of Continuity of Care Process
The Holman Group is committed to providing high quality mental health services, and strives toward excellence in customer service. We are truly invested in, and committed to, providing caring and effective treatment to our clients.
Prior to a new account’s benefits beginning, The Holman Group makes every effort to ensure patients currently receiving behavioral healthcare treatment (authorized by the previous behavioral healthcare insurance company) will continue to have access to his/her provider by attempting to contract with as many providers as possible (thereby ensuring there is no disruption in care).
A new enrollee inquiring about his/her provider’s status with The Holman Groups may contact the Care Access Department at 1- 800-321-2843 Monday through Friday 7:30 a.m. to 6:30 p.m.
If the provider the enrollee is requesting is already on the network, the Care Access Specialist will contact the provider and give them an authorization to see the enrollee.
If the provider the enrollee is requesting is not on the network, every effort will be made to ensure the enrollee utilizing an out-of-network provider and not experiencing acute or chronic conditions is provided appropriate continued care. This includes but is not limited to: attempting to contract with the provider; and/or providing the enrollee with the option of selecting an in-network provider.
In the event the provider is not part of The Holman Group network, a temporary transitional care benefit may be available to new enrollees. The transitional care benefit allows new enrollees to continue to receive services from a provider not on the network for a defined period of time or until the safe transfer of care to a network provider can be arranged. In order to qualify for the transitional care benefit an enrollee must have utilized medically necessary services provided by a licensed mental healthcare provider within thirty (30) days prior to the effective start date.
Please note: the availability of Transition of Care/Continuity of Care coverage does not mean a treatment is medically necessary. Nor does it constitute pre-authorization of the services to be provided. Medical necessity determinations and pre-authorization must still be obtained.
If a new enrollee is currently receiving services at an acute level of care (e.g. such as a psychiatric stabilization and detoxification), authorized by the current plan prior to the transition to the new plan, a benefit determination will be made by The Holman Group’s Behavioral Healthcare Advisor once the prior health plan is no longer providing coverage for the enrollee. Upon transition to Holman benefits, an enrollee who is receiving services at an acute level of care may be eligible for treatment at a different level of care.
When a provider/facility terminates as a contracted Holman Group provider every effort will be made to ensure that the transfer of enrollees to new providers will not disrupt or prevent care, and that the transfers are efficient and cause no unnecessary delays.
When a provider agreement terminates with The Holman Group the Provider Relations Department will coordinate with the Care Access Department to identify all affected members, inform them of the change and transition them to an in-network provider.
Holman will provide affected enrollees with the continuation of covered services from a terminated provider for a defined period of time (usually ninety (90) days) or until the safe transfer of care to a network provider can be arranged*, as long as the provider’s termination was not for medical or criminal disciplinary action.
*This will be determined by The Holman Group in consultation with the terminated provider.
In cases where the enrollee believes that health care services have been improperly denied, modified, or delayed by The Holman Group, or by one of its contracting providers, the enrollee has the right to file a complaint (grievance) with the plan. If an enrollee disagrees with the plan’s decision, needs help with a grievance involving an emergency, or a grievance has remained unresolved for more than thirty (30) days, the enrollee may contact The California Department of Managed Health Care (DMHC) for assistance. The Department has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired.
The enrollee may be eligible for an Independent Medical Review (IMR). If the enrollee is eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by the health plan related to the medical necessity of a proposed service, treatment, coverage decision for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical services.
Complaint forms, IMR application forms and instructions can be found online at the DMHC’s internet website, http://www.hmohelp.ca.gov.
The Holman Group will also furnish Independent Medical Review forms and addressed envelopes to enrollees as appropriate and required.
The DMHC may waive the requirement that the enrollee participate in the Plan's grievance process if they determine that extraordinary and compelling circumstances exist, which include, but are not limited to, serious pain, the potential loss of life, limb or major bodily function, or the immediate, and serious deterioration of the health of the enrollee.