Transitioning Between Non. Network and Network Providers for Medical and Behavioral Health The State recognizes that members upon enrollment in a Health Plan may transition between non-network and network providers to receive needed health care services (medical and behavioral). Contractor may require that non-network providers possess appropriate licensure, certification, or accreditation as required by the NCQA. This can occur when members first enrolls in a Health Plan, when members change Health Plans, or at other times. To ensure continuity of care, Contractor agrees to have written policies and procedures for transitioning between network and non-network providers the following types of members: • Individuals with developmental disabilities and individuals with serious and persistent mental illness (SPMI), • Those receiving services through the Rhode Island Department of Behavioral Health, Developmental Disabilities and Hospitals, or • Individuals receiving Medicare benefits enrolled in Rhody Health Options. Contractor shall routinely document the frequency of use from non-network to network providers in a format acceptable to EOHHS on an agreed upon schedule. These policies and procedures must contain a provision allowing members to continue seeing out-of-network providers for up to six (6) months after the member’s enrollment into the Health Plan. As described in Section 2.07.01, existing prior authorizations may require the Contractor to extend the six (6) month transition period. At the end of such period, in order to require that member transition to an in- network provider, Contractor must offer a provider with comparable or greater expertise in treating the needs of members. Contractor will ensure there is no cost to the member for the transfer of medical records during the transition period and thereafter, for efficient and seamless transfer of clinical care from one provider to another (in-network or out-of-network, primary or specialty care, including behavioral health).
