Transition Your Care & Prescriptions

Transition of Care (TOC) applies to members who are actively receiving treatment from a specialist and have appointments, surgeries, procedures, infusions or imaging services already scheduled within the first 90 days of enrolling in GHC-SCW coverage. TOC may also apply to members who are pregnant, use durable medical equipment (DME) or take prescribed medications that require ongoing management. 

Active treatment is defined as being seen by a specialist at least 2 times within the 3 months prior to starting GHC-SCW coverage. Annual visits with out of network specialists are not covered under Transition of Care as member is not under active treatment. Services must be a covered benefit and meet criteria. TOC services are not guaranteed. 

The Transition of Care process is different from your annual appointments or new appointments made for a medical or behavioral health condition. When you start your GHC-SCW coverage, you’ll establish appointments with your new Primary Care Provider for those things.

No. Primary Care Providers do not qualify for Transition of Care. Transition of Care is only for specialists that a member is under current active treatment.

You can call GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327 with any questions regarding plan providers, covered services, benefit coverage, location of clinics, co-pays and coinsurance. You can also search for your specialist on our Provider Search page.

Submit your TOC forms within 30 days of beginning coverage with GHC-SCW. This will allow GHC-SCW time to update your new insurance information and give our Transition of Care team an opportunity to review your form for any Transition of Care (TOC) needs. 

All scenarios below require a TOC form to be completed and submitted. 

If you are less than 28 weeks pregnant at the start of GHC-SCW coverage and seeing an out-of-network provider, you will need to transition your care to a new in-network OB/GYN provider.  

If you are more than 28 weeks pregnant at the start of coverage and seeing an out of network provider, you may stay with your current OB/GYN provider and delivery hospital. 

To verify if your behavioral health provider is in-network with GHC-SCW, visit our Provider search page or call Member Services (608) 828-4853 or (800) 605-4327. 

If your provider is out-of-network, you may qualify for Transition of Care, but services are not guaranteed. 

For CPAP/BiPAP, if you have completed more than 50% of the rent-to-own period (for example, 7 out of 12 months), GHC-SCW will allow you to finish with your current out-of-network DME provider before transitioning to an in-network provider. 

For continuous glucose monitors (CGM’s), specific criteria needs to be met for a member to receive continued coverage. 

Contact your specialist or provider that orders the medication. Your provider will need to submit a Prior Authorization to either GHC-SCW or Prime Therapeutics. The list of medications which require prior authorization can be found here. 

If the surgery is scheduled with an out-of-network provider, you will need to contact your specialist to have your care transferred to an in-network provider. 

If the surgery is scheduled with in-network provider, contact your specialist. They will need to submit a Prior Authorization to GHC-SCW for your procedure. 

Transition of Care limitations may apply with elective procedures; services are not guaranteed.

If the office visit is more than 90 days from the start of GHC-SCW coverage and the surgeon is out-of-network, you will need to contact your specialist to have your care transferred to an in-network provider. 

Complete a Transition of Care form with your current medications listed, a pharmacy representative will contact you if there is a question or special instructions needed. 

GHC-SCW provides information and guidance such as the medication formularies and a list of in-network pharmacies on the Understanding Your Pharmacy Benefits website.  

You will only be assigned a GHC-SCW PCP if one is not listed on your enrollment form. A PCP will be assigned to you based on where you live. You can change your PCP at any time by calling Member Services at (608) 828-4853 or (800) 605-4327. 

If your previous provider did not use EPIC charting, you will need to contact that health system and request your medical records to be faxed or sent to GHC-SCW. Otherwise, GHC-SCW is able to obtain records through EPIC Care Everywhere. 

Learn more about transferring your medical records here. 

Visit the Prior Authorization page on our website for a list. 

Your provider can go to the Prior Authorization page to submit a Prior Authorization to GHC-SCW. 

Once GHC-SCW receives a Prior Authorization form with appropriate documentation, it can take up to 15 calendar days to process routine requests. Most requests are handled within 7 days or less after receiving the prior authorization form. 

If a prior authorization request is urgent, please have your provider contact Care Management at (608) 257-5294 or (800) 605-4327 Ext. 4514.