If you get ongoing treatment from a provider who is not in the AmeriHealth Caritas Delaware network, you may be able to keep getting that treatment.
Treatment or services are "ongoing" if you were treated during the past 12 months for a condition that needs follow-up care or additional treatment. Services are also ongoing if they were already approved.
Continued care eligibility
You are allowed to continue ongoing treatment with a health care provider who is not in our network when any of the following happens:
- You are a new AmeriHealth Caritas Delaware member and you are getting ongoing treatment from a health care provider who is not in the AmeriHealth Caritas Delaware network.
- You are a current AmeriHealth Caritas Delaware member and you are getting ongoing treatment from a health care provider whose contract has ended with AmeriHealth Caritas Delaware for reasons that are "not-for-cause."
Reasons that are "not-for-cause" means the provider's contract did not end because of the quality of the provider’s care or because the provider did not meet other contract or regulatory requirements.
Can I get continued care?
|If you are...||AmeriHealth Caritas Delaware will allow you to...|
|A new AmeriHealth Caritas Delaware member||Keep getting treatment from a health care provider who is not in the AmeriHealth Caritas Delaware network. You can continue treatment for up to 90 days from the date you were enrolled in AmeriHealth Caritas Delaware or until the provider releases you from treatment.|
|A new AmeriHealth Caritas Delaware member and you are pregnant in your second or third trimester of pregnancy as of the date you enroll in AmeriHealth Caritas Delaware.||Keep getting treatment from an OB or midwife who is not in the AmeriHealth Caritas Delaware network until the end of your postpartum care (60 calendar days from delivery of the baby) related to your delivery.|
|A current AmeriHealth Caritas Delaware member and your health care provider (provider, midwife, or certified registered nurse practitioner) stops participating with AmeriHealth Caritas Delaware and you need to keep getting health care.||
|A current AmeriHealth Caritas Delaware member in your second or third trimester of pregnancy and the OB or midwife whom you see stops participating with AmeriHealth Caritas Delaware.||Continue going to the provider for treatment from that OB or midwife until you deliver your baby and receive postpartum care (60 calendar days from delivery of the baby) related to the delivery.|
Request continued care
Requests for ongoing treatment or services are reviewed case by case. If you want to keep getting treatment or services with a health care provider who is not in the AmeriHealth Caritas Delaware network, you must either:
- Call Member Services for help with continuing care.
- Ask your health care provider to call AmeriHealth Caritas Delaware’s Utilization Management department at 1-855-396-5770.
Once we have the request to continue care, we will review your case. We will notify your health care provider by phone if continued services have been authorized. If for some reason we do not approve continued care, your health care provider will get a phone call and letter that includes our decision and information about your right to appeal the decision.
Who cannot get continued care
You must get approval from AmeriHealth Caritas Delaware to continue care. AmeriHealth Caritas Delaware will not cover continuing care when:
- The provider's contract has ended because of quality-of-care issues.
- The provider is not a Delaware Medicaid provider.
- The provider did not comply with regulations or other contract requirements.
- The services are not ongoing.