ATT011_TransferHandbook.pdf

Member Transfer Handbook

WTC Health Program Member

Services & Enrollment Last

Revised: June 2025

Table of Contents Introduction and Overview

Conditions for Member Transfer

Transfer Exceptions

Member Transfer Process

Initiating Member Transfer at the Originating Clinic

TPA Confirmation of Enrollment and Eligibility

Coordination of Care Between Originating Clinic and Destination Clinic

Approval of Transfer by the Destination Clinic

Transition of Member After Transfer Approval

Administrative Responsibilities After Transfer Completion

Change History

Appendix A: Glossary of Terms

Appendix B: Transfer Checklist

Appendix C: Transfer Flowchart

Appendix D: WTC Health Program Transfer Process Point of Contact (POC) List

Appendix E: Exit Interview

Appendix F: Member Transfer Information Sheet

Appendix G: Abbreviated Medical Record Transfer Form

Appendix H: Mental Health Addendum

Appendix I: Transfer Letter Template

Appendix J: WTC-5 Medical Code Request Form

Member Transfer Handbook Published July 2014 Revised June 2025

Controlled Unclassified Information

Introduction and Overview This handbook describes the policy and procedure for member transfer for members of the Clinical Centers of Excellence (CCE) and Nationwide Provider Network (NPN).

Members of the World Trade Center (WTC) Health Program may transfer to a new clinic between the CCEs and/or the NPN. The term “clinic” refers to either a CCE in the New York City Metropolitan Area (NYCMA), or the NPN that serves members outside of the NYCMA.

Member transfers may occur between Responder CCEs (General Responder and FDNY), Survivor CCEs, or between any of the clinics and the NPN. Survivors or FDNY uniformed active responders may not request a transfer to the NYCMA General Responder CCEs.1

When members request to transfer from their current clinic (the originating clinic), their care must be coordinated with the clinic to which they are transferring (the destination clinic). The destination clinic must review the member’s medical records and current treatment services. If the destination clinic determines that the NYCMA Program Codebooks do not include any needed medical procedure codes, they should submit a WTC-5 Medical Code Request Form (Appendix J). When a member transfers, the Third-Party Administrator (TPA) is responsible for creating a member claims report to ensure continuity of benefit coverage for the member. The report should include claims with dates of service (DOS) in the past 12 months.

TPA is also involved in the member transfer process, as the entity responsible for the collection, storage, and archiving of member data. The originating clinic, the destination clinic, and the TPA must use the WTC Health Program Member Transfer Module (MTM) to process a member transfer. The MTM is an online application that allows for the secure transfer of member care, medical records, and clinic assignment status between the CCEs, NPN, TPA, and WTC Health Program.

The originating clinic, destination clinic, and TPA must follow the process outlined in this document to ensure that members’ medical records and clinic assignment are properly coordinated to avoid any interruption in care. A glossary of terms is included in Appendix A.

Conditions for Member Transfer Members of the WTC Health Program may transfer to a new clinic between the CCEs and/or the NPN without prior approval from the WTC Health Program under any one of the following circumstances:

1. Time-Determined Transfer Members may transfer for any reason if it has been at least one year since their last transfer. Generally, this means that members need to stay with a clinic for at

1 Reclassification of members between NYCMA Responder and Survivor Programs may be considered under certain circumstances. Refer to <<Reclassification Process>> for procedures related to member reclassification between NYCMA Responder and Survivor Programs.

least one year (the “year rule”). However, members who request a transfer within their first year of enrollment are also able to transfer without prior approval. In this case, the “year rule” takes effect after a member is assigned to the destination clinic.

2. Urgent Transfers For urgent transfers, the originating CCE/NPN must initiate a conference call with the destination clinic and the NIOSH Transfer Team to discuss the case to ensure continuity of care. The originating CCE/NPN submits the transfer request in the MTM and marks it as urgent. The destination clinic must respond to the request within 48 hours or 2 business days. The NIOSH Transfer Team will receive an email notification of the request and will follow up with the destination clinic if a decision is not made within 48 hours or 2 business days of the MTM request submission. Urgent transfers are defined as transfers for members who are in active treatment who need medical services that cannot be provided by the CCE. The benchmark is “Does the member need specific care where, if the member does not receive said care within 30 days, it would be detrimental to their overall health and wellbeing?”

• Transplant member

• Active cancer treatment

• Disruption in care due to relocation

• Pending surgical treatment within 30 days

• Acute symptoms that require diagnostic

• Acute / Ongoing Intensive Mental Health Needs

* Please note: Exceptions may apply to this Rule.

3. Clinic Reassignment Members may request to change clinics prior to intake before any records have been generated. Because no records are being transferred, clinic reassignments do not require a signed Release of Information (ROI) and should be completed within five business days. To submit a clinic reassignment request, the originating clinic must check the “Clinic V1 Reassignment” box in the MTM.

There is one exception to this, and it involves members who have been auto-assigned to the NPN but request re-assignment to a CCE after they have completed the exposure questionnaire. While these members have a record, (i.e., the exposure questionnaire), the originating clinic, the NPN, can submit re-assignment requests of this type by checking the “Clinic V1 Reassignment” checkbox in the MTM, as described above. The NPN must include in the notes of the reassignment that the member was auto-assigned to the NPN post-enrollment and also include the date the exposure questionnaire was completed. The exposure questionnaire does not need to be attached to the reassignment, as no signed ROI is required.

4. Geographically-Determined Transfer Members may request to change clinics in the event of a geographic relocation that results in difficulty traveling to their current clinic. For example, if an NYC-based member moves to Florida, they would likely want to transfer to the NPN.

This type of transfer does not require approval from the WTC Health Program.

5. Disruptive/Discharged Member Transfer For transfers of members who are disruptive, abusive, or show threatening behavior and are discharged or have requested to transfer from the Originating Clinic, the originating CCE/NPN must initiate a conference call with the destination clinic and the NIOSH Transfer Team to discuss the member’s case and to ensure continuity of care. The originating CCE/NPN submits the transfer request in the MTM upon receipt of ROI. The destination clinic must respond to the request within 48 hours or 2 business days. The NIOSH Transfer Team will receive an email notification of the request and will follow up with the destination clinic if a decision is not made within 48 hours or 2 business days of the MTM request submission. Destination Clinic may consider establishing a Behavioral Contract with Member as a condition of acceptance.

Transfer Exceptions Transfer exceptions require prior approval from the WTC Health Program through a transfer exception. For urgent transfer requests that involve an exception, the NIOSH Transfer Team will respond to the urgent request within 1 business day or 24 hours of the originating clinic’s submission. For urgent transfer exceptions that are approved by the NIOSH Transfer Team, the destination clinic must respond to the urgent transfer exception within 48 hours or 2 business days of NIOSH’s approval. The three main types of transfer exceptions include:

1. Exception to Care Generally, members who live within the NYCMA or New Jersey (NJ) catchment area attend a Responder or Survivor CCE, and members who do not live within the NYCMA or NJ catchment area attend the NPN. However, members in the NYCMA or NJ catchment area may request an “exception to care” if they would like to transfer to the NPN, and members who do not live within the NYCMA or NJ catchment area may request an “exception to care” if they would like to transfer to a CCE.

Exceptions to care need to be approved by both the originating clinic and the WTC Health Program. Typically, members only receive approval in such situations if they have a demonstrated need to attend the NPN (e.g., mobility limitations) or have a demonstrated need to attend a Responder or Survivor CCE (e.g., an inability to locate a provider in their area). The responsibility of ensuring sufficient medication involves the originating clinic and the member until transfer completion (i.e., destination clinic transfer approval is granted).

Members, who do not live within the NYCMA or NJ catchment area and want to transfer to a CCE, are responsible for paying out-of-pocket travel costs (for example, lodging, gas, parking, tolls, meals, etc., while traveling for appointments and services).

2. Transfer Mid-Monitoring Unlike members at the CCEs, NPN members complete their monitoring exam in three parts: exposure and medical questionnaire, work-up (labs), and a provider visit. Due to the administrative and financial burden of duplicate testing, a request for transfer exception needs to be submitted for NPN members wishing to transfer to a CCE between completing work-up and the provider visit.

3. Monitoring Exams via Telehealth When members receive monitoring exams via telehealth and they want to transfer, the originating clinic must submit the transfer as an exception in the

MTM.

4. FDNY Family Members When a FDNY family member transfers to the NPN, the originating clinic must submit the transfer as an exception in the MTM and note this is a FDNY family member in the Request Description field.

Member Transfer Process In order to initiate the member transfer process, members must request a transfer from the clinic to which they are currently assigned. If the member tries to request a transfer from the WTC Health Program, the TPA, or a clinic other than the one to which they are currently assigned, then they should be directed back to their originating clinic to initiate the transfer. Members initiate transfers by completing and signing a ROI form and providing it to their originating clinic.

The member should be offered assistance from the appropriate contact at their originating clinic.

If a destination clinic learns that a member is having difficulty with their originating clinic, the destination clinic should contact the originating clinic to notify them of the transfer request. The originating clinic should then follow up with the member and address their concerns. The WTC Health Program may be contacted for policy-related issues including, but not limited to, instances where members request transfer and receive an ROI form but do not return the form to their originating clinic. If a member does not return their ROI within 14-business days from the date they were provided the form in person or electronically, or within 21 business days via mail, the originating clinic must contact the member to obtain justification for the delay

If a member requests a transfer but notifies the originating clinic that they have changed their mind before medical records have been sent to the destination clinic, this is considered a cancellation and is permitted under this policy. A cancellation does not require approval from the WTC Health Program. If the request occurs after medical records have been sent, then the transfer must be completed in the MTM, though the destination clinic retains the right to accept or deny the transfer. If the destination clinic has accepted the transfer, they may initiate a transfer back to the member’s originating clinic outside of the transfer exception process (in other words, the destination clinic can transfer the member back without having to submit the request as a transfer exception in the MTM).

The following steps describe the member transfer process in terms of the roles and responsibilities of the involved parties including the originating clinic, the destination clinic, and the TPA. A Transfer Checklist (Appendix B) is provided to facilitate the process, with a Transfer Flowchart (Appendix C) available as a quick reference guide.

Initiating Member Transfer at the Originating Clinic

1. When a member informs their current clinic that they want to transfer, the clinical staff must inform the transfer POC at their clinic (Appendix D). Each clinic may have additional internal policies regarding the protocol to follow when members transfer out of their clinic.

a. If a clinic is transferring a member with a history of behavioral issues or needs that should be handled in a more sensitive manner during the transfer of care, then the originating clinic must notify the WTC Health Program to discuss these issues. This may include members who have active substance abuse, persistent or severe mental health conditions, behavioral or disciplinary issues, drug-seeking or “doctor shopping” behaviors.

b. The WTC Health Program will serve as a liaison with the member, the originating clinic, and the destination clinic during the transfer process. In some cases, the originating clinic may coordinate a call with the WTC Health Program POCs and the designation clinic to discuss the member. The outlined process will still occur, but only after agreement between both the originating and destination clinics is reached to start the process.

2. For urgent transfer requests, the originating clinic must select the “Urgent” checkbox in the MTM to generate a notification email to all parties. They must also make a phone call to the destination clinic’s transfer POC. An example of an urgent request is a member who is moving to a new area and needs immediate medical attention.

3. The originating clinic will determine if the member is registered with the WTC Health Program by verifying that the member is present in the system at their Data Center.

4. The CCE/NPN transfer POC should conduct an Exit Interview2 (Appendix E) with the member to discuss the changes that would take place with respect to the member’s healthcare. They should also provide the member with a copy of the Member Transfer Information Sheet (Appendix F). The member should be informed that:

a. Once a transfer is complete, their WTC-related health care will be handled by the destination clinic, including all WTC-related treatment services, medical care, and mental health care.

b. They can only transfer once a year unless special circumstances justify a transfer exception.

c. WTC monitoring and treatment services (if applicable) will be shifted to the requested destination clinic, and though they will go through another intake process, they will remain on the same monitoring schedule. This means that responders and certified-eligible survivors will get their first monitoring exam at their new clinic approximately one year after their last exam at their last clinic.

Screening-eligible survivors will not get another initial health evaluation;

however, they retain the right to pay out-of-pocket for an additional health evaluation.

d. Any care (e.g., surgeries, lab test, and/or procedures such as CT scan) which are currently pending at the originating clinic will be evaluated through administrative consultation with the destination clinic. Some pending care may need to be cancelled and re-initiated by the requested destination clinic. Please note that transfer during a pending certification should be discouraged.

e. Any medications which the member is currently receiving will no longer be provided through the originating clinic, though members should have a discussion with their originating clinic about adequate medication coverage during and after the transfer process. Members will need to be evaluated by the destination clinic to obtain further medication after the transfer is completed. If members are referred by the destination clinic to services in the community, the destination clinic will be responsible for the case management of the member once the transfer is finalized. The originating and destination clinic should

2 Reporting requirement on semi and annual report and technical guidance document created.

coordinate to ensure that members do not have a lapse in medication.

f. Exit interviews should be completed prior to sending the member ROI form, if applicable. During the exit interview, the originating clinic should ascertain the member’s reason for transfer, discuss differences between their current clinic and the clinic they are transferring to, which includes, but is not limited to, education on out-of-pocket transportation costs, in-house providers versus preferred provider networks, and ensuring that transferring members are provided with information on providers (within a 250-mile radius) of the area of which they are transferring to. In addition, members must be notified that all their care will be transferred to and provided by the destination clinic.

5. The transferring member must complete an ROI form before any records or demographic information can be released by the originating clinic or the HPS contractor to the destination clinic.

a. Transfers resulting after a reclassification also follow the aforementioned guidelines including a completed ROI form. Originating clinics transferring reclassified members have up to 7 business days from the date of reclassification completion (i.e., reclassification effective date) to contact the member to obtain their medical records release form to initiate the transfer request to the destination clinic. Destination clinics receiving transferred members post-reclassification have up to 7 business days post transfer acceptance to ensure that TPA-Enrollment has updated all systems with the correct information including CCE designation TPA Plexis database and NIOSH’s Centralized Accessible Realtime Enterprise (CARE) application database which populate the MTM. This will ensure that transferred members can receive services and care in a timely manner post-transfer.

6. To initiate the member transfer after the ROI is received, the originating clinic should add the request in the MTM. Only the originating clinic can initiate a transfer in the MTM.

7. The originating clinic should choose the member’s selected destination clinic in the MTM, while providing a reason for the transfer request. The originating clinic may proceed with the transfer request if the reason for the transfer is because (1) it has been more than 12 months since the member last transferred, or (2) the member will move/has moved out of the area. All other requests will require approval by the WTC Health Program via a transfer exception.3

8. After the originating clinic initiates the transfer in the MTM, a system-generated email notification is sent to the TPA, the Data Centers, and the destination clinic, making them aware of the transfer request. The system email will include the following:

a. Transfer initiation notice

b. Member 911 number

c. Originating clinic

d. Destination clinic

3 If the member transfer request requires a transfer exception, the request will be sent to the WTC Health Program via the MTM. If the WTC Health Program approves the member transfer, the originating clinic will be notified, and the request will be forwarded to the destination clinic. If the WTC Health Program denies the member transfer, the originating clinic will be notified of the reason for the denial.

TPA Confirmation of Enrollment and Eligibility

1. Upon receiving a notification that a transfer request has been initiated, the TPA will attach a member Transfer Report to the request within the MTM and/or within the CARE portal (for the transfers that occur manually, outside of the MTM). The Transfer Report will include:

a. 911 number

b. First and last name

c. Address

d. Date of birth

e. Gender

f. Phone number(s)

g. Email address

h. Certification record, including all WTC-related health conditions and health conditions medically associated with a WTC-related health condition.

i. Member claims history for DOS in the past 12 months.

j. Responder Sub Type

Coordination of Care Between Originating Clinic and Destination Clinic

1. When the originating clinic has (1) confirmed that the transfer may be initiated, (2) has informed the member of the transfer conditions as stated above, and (3) has received a completed and signed ROI form from the member, then the member’s records can be sent to the requested destination clinic via the MTM. The transfer process must be completed within 30 days4 of the member providing a signed ROI form, in accordance with the HIPAA Privacy Rule regulation on timely access to protected health information (45 CFR 164.524(b)(2)).5

2. The originating clinic must complete the Abbreviated Medical Record Transfer Form (Appendix G) to facilitate the transfer of medical records. The following records should be delivered to the destination clinic, as applicable: all treatment records, medication records, mental health records (with the exception of psychotherapy notes), external medical records, the first and last monitoring exam and current Other Health Insurance (OHI) information for Survivor members.

3. For transfers between clinics that use Trial DB6, any records that are not available in Trial DB must be sent to the destination clinic via mail or a secure portal that is accessible to both the originating and destination clinics. Alternatively, where feasible, the originating clinic may scan and send the medical records (physical and/or mental health) to the destination clinic via CARE.

4. If the member is receiving treatment for a certified mental health condition at the originating clinic and is seeking ongoing care, the destination clinic must consult with the originating clinic to determine appropriate transfer of care. The originating clinic must also make the following available to the destination clinic, as applicable, facilitated by the required Mental Health Addendum (Appendix H):

a. Mental health clinical summary;

4 Completed transfer in excess of 30 days requires written explanation.

5 If there are no medical records to be sent, the current CCE can request a reassignment by the HPS Contractor as opposed to a transfer (as per Section IV.C. of the policy).

6 Trial DB is the records management system used by the Mount Sinai Data Center and shared by NYMCA Responder clinics. Trial DB is not used by HHC, LHI, or the FDNY clinics.

b. List of conditions certified for treatment and conditions that are being treated under the rubric of medically necessary care;

c. Date and outcome of most recent mental health monitoring exam;

d. Mental health intake assessment;

e. Psychological testing results;

f. Medication management treatment notes;

g. List of current medications as well as date/supply of most recent prescription, along with name and contact number of prescribing clinician;

h. Date of last psychotherapy session, if applicable;

i. Discharge summary related to any psychiatric hospitalization;

j. Reason the member is seeking transfer; and

k. Name and contact information of a clinician on the member’s treatment team who can provide detailed information about the member’s disposition/course of treatment should questions arise. Clinics should ensure that contact information for Points of Contact are up-to-date and reviewed at least once quarterly.

As a reminder, mental health records should be sent separately from physical health records. Psychotherapy (individual or group) notes should not be included in the medical records sent to the destination clinic. Clinical contacts at the originating and destination clinics should schedule a call to discuss relevant psychotherapy-related information.

5. The transfer POC at the originating clinic should coordinate with the appropriate transfer POC (i.e., primary or mental or physical health POC) at the destination clinic for appropriate transition of the member’s case management. The originating clinic’s transfer POC should not terminate case management services, or any other services covered by the Program, until the transfer is approved by the destination clinic, and the originating clinic has received notification of the acceptance.

Approval of Transfer by the Destination Clinic

1. The destination clinic has the right to review member’s records prior to acceptance of transfer. The destination clinic should contact the originating clinic to perform an administrative consultation to discuss the case in detail, including the member’s clinical status. As a reminder, the entire transfer process should not exceed 30 days.

2. The destination clinic may require certain stipulations to be met in order to approve a member’s transfer request. This includes requirements regarding member behavior, additional evaluation measures, adherence to treatment recommendations and, for Survivors, this may also include a requirement to provide current Other Health Insurance information. To ensure that the member understands the destination clinic’s expectations, the destination clinic may contact the member directly to reach an agreement prior to accepting transfer. Please note that NIOSH is available to participate, if necessary.

3. During review of the case, the following issues may arise regarding certifications:

a. If it is determined that the originating clinic was preparing to submit a certification request, then the destination clinic may, if appropriate, complete the certification request using the WTC-3 process.

b. If a certification was not pursued by the originating clinic because they determined that there was a lack of WTC-relatedness to the condition, the destination clinic may not provide treatment unless and until it is determined that there is sufficient information to pursue a certification.

c. If the originating clinic determines that a certification was insufficient or lacked WTC-relatedness during the initial certification review and during secondary review, the destination clinic may opt not to pursue certification for that same condition again.

d. If the destination clinic decides not to accept the member, then they must first consult with the WTC Health Program and provide justification for the denial before entering it into the MTM. Valid reasons for denying acceptance of a member are primarily due to documented behavioral issues such as:

i. Acts of violence or threats against staff or other patients, including verbal or physical abuse

ii. Rude or vulgar language, including cursing and shouting

iii. Engaging in criminal behavior

4. If member has a history of non-compliance (i.e., missing appointments) the Program recommends that the destination clinic first speak to the member and notify NIOSH of the member’s history of non-compliance while including written documentation of the non-compliance (i.e., missed appointments with dates included and/or a history of repeated appointment cancellations with dates included). Prior to transfer acceptance and finalization, NIOSH will send the member a letter of non-compliance equipped with the member’s roles and responsibilities as a Program member, including being compliant and attending scheduled appointments and the consequences of non-compliance.

5. The WTC Health Program will review all denials submitted into the MTM before they are finalized.

Transition of Member After Transfer Approval

1. The originating clinic must coordinate with the destination clinic to evaluate all active pre-authorizations with external providers prior to final transfer. The Abbreviated Medical Record Transfer Form (Appendix G) and the Transfer Checklist (Appendix B) enable both the originating clinic and the destination clinic to see that all services related to the member have been properly coordinated to maintain continuity of care where possible, including mental health care.

2. The transfer POCs at the originating and the destination clinic should communicate concerning any durable medical equipment (DME), such as a CPAP or BIPAP, that the member is currently using. The current DME provider would need to be identified to determine if they are in-network for the destination clinic. If the current DME provider is in-network, then the destination clinic can work with the member to update the DME provider of the change. If the DME provider is not in-network, then the destination clinic could attempt to bring them into their network or work with the member to switch to a provider in-network in order to prevent a lapse in treatment.

3. The transfer POCs at the originating and the destination clinics must discuss the management of the member’s health care in the interim period until such time that the member can be seen at the destination clinic.

4. The transfer POCs at the originating and destination clinics should coordinate any cancer treatment that the patient is receiving by identifying the current cancer treatment provider and determining if this provider is in-network, out-of-network, or in-network via a single-case agreement (SCA) contract with the originating clinic only. If the provider is in network via SCA, the destination clinic will have to bring that provider in network via the TPA contracting team or work with the member to switch to an in-network provider.

5. Once the medical records have been reviewed by the destination clinic, and the member transfer request has been approved in the MTM, the transfer is considered complete. The destination clinic will initiate first call attempt to member within 3 business days after the transfer7 is received to establish the relationship with the member, to initiate services, and to confirm current Other Health Insurance (OHI) for Survivor members.

Administrative Responsibilities After Transfer Completion

1. The TPA will send a Transfer Letter (Appendix I) notifying member that their transfer is complete. The letter will include the destination clinic POC information. The TPA will then update their internal system to reflect the member's new clinic affiliation.

2. The destination clinic may set up an appointment with the member. The appointment will be documented in EHR/EMR and the destination clinic will notify the member of the appointment information. The member will also be provided with a reminder by the destination clinic prior to their appointment.

3. Any outstanding appointments made by the originating clinic should be cancelled unless a decision has been made between the originating and destination clinic to maintain appointments for continuity of care. If an appointment is not cancelled, it should be billed by the provider at the originating clinic. Note that continued care by the originating clinic is generally not allowed after a transfer has been approved unless authorized by the destination clinic.

4. The effective date of the transfer is determined by the destination clinic’s acceptance date in the MTM. For example, if a transfer is accepted on 5/19 in the MTM, then the last day that the member is with the originating clinic is 5/18 and the first day with the destination clinic is 5/19. For destination clinics that use Trial DB, the transferred member’s effective date in Trial DB would be 5/19.

7 Note: The requirement to call the member within 3 business days of transfer completion is included on the semi-annual and annual report checklist.

Change History

A. September 2022: Clarified administrative responsibilities after transfer completion related to the NPN medical code change process. Updated Appendices B, E, G, H with latest forms.

Added change log and captured changes from previous version.

B. June 2022: Added introductory text to clarify the medical code change process related to member transfer. Clarified responsibilities for ensuring sufficient medication during transfer.

Included information related to travel costs for members requesting CCE transfer outside the NYCMA and NJ catchment areas. Updated document title and Appendices A-J for editorial and stylistic updates.

C. May 2023: Updated Page 11 Administrative Responsibilities after Transfer Completion, removed Step 1 regarding Medical Records and Claims History for the past 12 Months and the submission of a WTC-5 and Codebook Updates if required. Updated Appendix D NIOSH Contact, HPS Contact and HHC Contact information.

D. June 2023: Updated Appendix D to MCA Contact page 22 and Rutgers Contact page 25.

Updated Page 7 TPS Responsibility for Demographic report data to include Responder Sub Type in the Transfer Report.

E. Sept 2023 Pg 8 part 2, Pg 9 part 2 and page 10 part 5 language to add OHI

F. Sept 2023 New AMR Appendix G to replace the old Appendix G on page 30

G. April 2024 Pg 3 Conditions for Member Transfers Urgent Transfer, add statement as shown and pg 21 add Amy Sams only as Primary POC for WSC

H. June 2024 Updated pg 3 Part 2 Urgent Transfers add “the NIOSH Transfer Team to”, Pg 4 add item 5 for Disruptive Member, Pg 5 under Member transfer process add “21 business days”, Pg 11 #5 add “3 business days” and page 11 Bottom of page add “3 business days”.

I. June 2025 Reformatted and updated Appendix D, Point of Contact List; replaced Appendix H, Mental Health Addendum with updated form.

xup8 Underline xup8 Underline

Appendix A: Glossary of Terms

Term Definition Approval of Transfer Occurs when a destination clinic decides to accept a member transfer. The date the transfer is approved is the effective date of the transfer. As an example, if a transfer is accepted on 5/19 in the MTM, then the TPA’s records and Trial DB should show the member’s last day with the originating clinic to be 5/18 and the first day with the destination clinic as 5/19.

Cancellation of Transfer Occurs when a member changes their mind about transferring before medical records have been sent to the destination clinic.

Cancellations do not require approval from the WTC Health Program. If the member changes their mind after medical records are sent, the transfer must be completed. The member will not have to get a transfer exception to transfer back to their original clinic.

Clinic Reassignment Allows members to change clinics prior to intake before the member has any medical records. This is not considered a transfer, and so the Year Rule takes effect after the member is assigned to the new clinic. Reassignments do not require prior approval from the WTC Health Program.

Denial of Transfer Occurs when a destination clinic decides not to accept a member transfer. The destination clinic must provide a justification for the decision (i.e., capacity) to the WTC Health Program, and the Program will have to approve the denial before it is entered into the

MTM.

Destination Clinic A clinic that a member is requesting a transfer to.

Exception to Care Occurs when a member lives within the NYCMA/NJ Catchment area and they want to transfer to the NPN or when a member lives outside the NYCMA/NJ Catchment area and they want to transfer to a CCE.

Exit Interview Should occurs when a member initiates transfer. The originating clinic should ascertain the member’s reason for transfer, discuss differences between their current clinic and the clinic they are transferring to, which includes, but is not limited to, education on out-of-pocket transportation costs, in-house providers versus preferred provider networks, and ensuring that transferring members are provided with information.

Geographically-Determined Transfer

An exception to the Year Rule. Allows members to request a transfer in the event of a geographic relocation and/or address change. This type of transfer does not require prior approval from the WTC Health Program.

Initiation of Transfer Occurs when a member requests a transfer from their originating clinic by submitting an ROI form. Once the member returns a signed

ROI the originating and destination clinics have 30 days to complete the transfer. The transfer request should be documented in the

MTM.

Member Transfer Module

(MTM)

An online application located in the CARE portal that allows for the secure transfer of member care and medical records between the CCEs, the NPN, the HPS Contractor, and the WTC Health Program.

Mid-Monitoring Occurs when an NPN member has an incomplete monitoring exam and wants to transfer to a CCE or when any member had their monitoring exam via telehealth.

Originating Clinic A member’s current clinic that they are requesting a transfer from.

Time-Determined Transfer See the Year Rule.

Transfer Exception Occurs when member wants to transfer to a new clinic, but 1) it has been less than twelve months since the member last transferred, and 2) the member is not requesting a geographically determined transfer. These requests do require prior approval by the WTC Health Program.

Transfer Post-Reclassification Occurs after a member’s enrollment reclassification from a Survivor to Responder and is completed manually out of the MTM Portal.

Updates are sent via CARE Web Portal

Trial DB Records management system used by the Mount Sinai Data Center and shared by NYC Metropolitan Area General Responder clinics.

Trial DB is not used by HHC, NPN, or the FDNY clinics.

Year Rule Restriction stating that members may only request to change their clinic once a year, barring special circumstances (ex:

geographically determined transfer, clinic reassignment). Also known as a Time-Determined Transfer.

Appendix B: Transfer Checklist

Appendix C: Transfer Flowchart

Request transfer from current clinic.

Inform transfer POC at clinic.

Verify member presence in Data Center system.

MEMBERS

ORIGINATING CLINIC

THIRD-PARTY ADMINISTRATOR

DESTINATION CLINIC

Conduct exit interview:

review transfer protocol and changes that may occur.

Ensure member has copy of member transfer info sheet.

Complete ROI/HIPAA medical records release.

Initiate transfer in Member Transfer Module (MTM).

Send TPA contractor any updates to member information via CARE.

Transfer process begins.

Attach Transfer Report to transfer request in MTM.

Compile member information for transmission to DC Data Center.

Transfer process begins.

MEMBERS

Confirm that transfer may be initiated.

Send member records to DC via

MTM.

Accept the transfer.

Reject the transfer.

Coordinate transition of case management with appropriate DC

Point of Contact.

Notify OC and HPS contractor via the MTM.

Authorize and take over case management.

Coordinate with DC to evaluate active pre-authorizations and maintain continuity of care where possible.

DESTINATION CLINIC

Perform administrative consultation to discuss member’s case.

Consult with WTC Health Program and provide justification for denial.

ORIGINATING CLINIC (OC)

Discuss durable medical equipment (DME) and management of member’s care before first appointment.

Transfer process complete.

Call member to set up first appointment.

Initiating a Transfer: Up to 30 days to complete after ROI is signed by member. Transfers that take more than 30 days require written justification.

Appendix D: WTC Health Program Transfer Process Point of Contact (POC) List

NIOSH

Address Attn: WTC Health Program 2400 Century Parkway NE Atlanta, GA 30345

Primary POC Evangela Blake Tel: 404-498-2964 Fax: 404-471-2608 Email: pt5K@cdc.gov

Rachel Culver Tel: 404-498-2692 Fax: 404-471-2608 Email: vwt1@cdc.gov

Additional POC LaToya Luck Tel: 404-498-2364 Fax: 404-471-2608 Email: ba67@cdc.gov

Third Party Administrator (TPA)

Address Attn: WTC Health Program P.O. Box 7000 Rensselaer, NY 12144

Primary POC Myetta Carney Tel: 301-287-4058 Email: Myetta.Andrus-Carney@gdit.com

FDNY Headquarters

Address 9 Metro Tech Center Brooklyn, NY 11201

Administrator/Director Jessica Weakley Tel: 718-999-0412 Fax: 718-999-0681 Email: Jessica.Weakley@fdny.nyc.gov

Primary POC Sofia Bakradze Tel: 718-999-1937 Fax: 718-999-0681 mailto:pt5K@cdc.gov mailto:vwt1@cdc.gov mailto:ba67@cdc.gov mailto:Myetta.Andrus-Carney@gdit.com mailto:Jessica.Weakley@fdny.nyc.gov

Email: Sofia.Bakradze@fdny.nyc.gov

Elina Cruz Tel: 718-999-5155 Fax: 718-999-0681 Email: Elina.Cruz@fdny.nyc.gov

HHC Survivor Program

Address WTC Environmental Health Center 160 Water Street, Room 1055 New York, NY 10013

Administrator/Director Scott VanOrden Tel: 646-458-2711 Fax: 212-788-1113 Email: Scott.VanOrden@nychhc.org

Additional POC Sharon Abbott Tel: 646-659-8414 Fax: 212-788-1113 eFax: 347-671-8406 Email: sharon.abbott@nyhhc.org

Michelle Hyde Tel: 917-239-3874 Alt Tel: 212-778-0949 Email: michelle.hyde@nyhhc.org

Fabiola Salerni Tel: 646-815-3004 Email: salernif@nyhhc.org

Optum Serve

Address 328 Front Street South LaCrosse, WI 54601 Email for transfer notifications:

WTCNPtransfers@logisticshealth.com

Administrator/Director Holly Nickelatti Tel: 877-498-2911 x52150 Fax: 608-783-7532 Email: hnickelatti@optumserve.com

Primary POC Amy Sams (Case Management) Tel: 800-714-7426 x52573 Fax: 877-348-4968 Email: asams@optumserve.com

Lisa Gray Tel: 877-498-2911 x52822 mailto:Sofia.Bakradze@fdny.nyc.gov mailto:Elina.Cruz@fdny.nyc.gov mailto:Scott.VanOrden@nychhc.org mailto:sharon.abbott@nyhhc.org mailto:michelle.hyde@nyhhc.org mailto:salernif@nyhhc.org mailto:WTCNPtransfers@logisticshealth.com mailto:asams@optumserve.com

Fax: 608-793-2964 Email: lgray@optumserve.com

Additional POC Kassondra “Kassie” Puchalski Tel: 877-498-2911 x52362 Fax: 877-358-4968 Email: kpuchalski@optumserve.com

Managed Care Advisors (MCA)—Sedgwick

Address 555 Glendon Ct.

Dublin, OH 43016

Administrator/Director Susan Kappel Tel: 301-469-1660 x170 Email: skappel@managedcareadvisors.com

Primary POC Gina Sun Tel: 800-416-2898 x2015 Email: gsun@managedcareadvisors.com

Dorene Hurley Tel: 800-416-2898 x4875 Email: dorene.hurley@sedgwickgovernment.com

Potential Member Provider Requests—Dorene Hurley Tel: 800-416-2898 x4875 Email: transfers@sedgwickgovernment.com

Additional POC Zainab Ameer Tel: 800-416-2898 x1015 Email: zameer@managedcareadvisors.com

Leesa Harrie (Outbound Transfers) Tel: 929-577-9260 x9260 Email: lharrie@managedcareadvisors.com

Dr. Tim Bergan Tel: 929-920-5348 x5348 Email: tbergan@managedcareadvisors.com

Mental Health POC Dr. Tim Bergan Tel: 929-920-5348 x5348 Email: tbergan@managedcareadvisors.com

Mount Sinai School of Medicine

Address 1468 Madison Avenue, 3rd Floor (Annenberg Building) New York, NY 10029

Administrator/Director Julia Nicolaou-Burns Tel: 212-241-0894 Fax: 212-987-1134 mailto:lgray@optumserve.com mailto:skappel@managedcareadvisors.com mailto:gsun@managedcareadvisors.com mailto:dorene.hurley@sedgwickgovernment.com mailto:transfers@sedgwickgovernment.com mailto:zameer@managedcareadvisors.com mailto:lharrie@managedcareadvisors.com mailto:tbergan@managedcareadvisors.com mailto:tbergan@managedcareadvisors.com

Email: Julia.nicolaou@mssm.edu

Primary POC Christina Abbatiello Tel: 212-241-0637 Fax: 212-241-6007 Email: Christina.Abbatiello@mssm.edu

Additional POC Tassy Carilice Tel: 212-824-9736 Email: Tassy.Carilice@mssm.edu

Valerie Lippman Tel: 212-824-7063 Email: Valerie.Lippman@mssm.edu

Mental Health POC Natalia Bakula (Administrative) Tel: 212-241-8462 x30015 Fax: 212-241-3381 Email: Natalia.Bakula@mssm.edu

Moneque Frazier (Administrative) Tel: 212-241-8462 x30015 Fax: 212-241-3381 Email: Moneque.Frazier@mssm.edu

Amy Cushing-Savvi, LCSW Tel: 212-241-7756 Email: Amy.Cushing-Savvi@mssm.edu

Andrea Greene, LCSW Tel: 212-241-0636 Email: Andrea.Greene@mssm.edu

Massielle Morales-Miller, LCSW Tel: 212-241-2773 Email: Massielle.Morales-Miller@mssm.edu

Richmond University Medical Center (Staten Island)

Address 690 Castleton Avenue, 2nd Floor Staten Island, NY 10310

Primary POC Elba Rios Tel: 718-390-1308 Fax: 718-420-6503 Email: Elba.Rios@mssm.edu

New York University School of Medicine

Address WTC Health Program Clinical Center of Excellence Occupational & Environmental Medicine 462 First Avenue, 7th Floor, Suite A726 mailto:Julia.nicolaou@mssm.edu mailto:Christina.Abbatiello@mssm.edu mailto:Tassy.Carilice@mssm.edu mailto:Valerie.Lippman@mssm.edu mailto:Natalia.Bakula@mssm.edu mailto:Moneque.Frazier@mssm.edu mailto:Amy.Cushing-Savvi@mssm.edu mailto:Andrea.Greene@mssm.edu mailto:Massielle.Morales-Miller@mssm.edu mailto:Elba.Rios@mssm.edu

New York, NY 10016 Attn: Transfers Staff

Administrator/Director Lin Y. Luo Tel: 646-754-1650 Fax: 646-754-9806 Email: linyong.luo@nyulangone.org

Primary POC Jesse Martinez-Duperon Tel: 212-562-4572 Fax: 212-562-4574 Email: wanda.martinez-duperon@nyulangone.org

Additional POC Grace Zheng Tel: 646-754-1651 Fax: 646-754-9806 Email: grace.zheng@nyulangone.org

Mental Health POC Peter Haugen, PhD Director of Mental Health Tel: 646-754-1637 Fax: 646-754-9806 Email: peter.haugen@nyulangone.org

Physical Health POC Trace Rosel, LCSW Tel: 646-754-1637 Fax: 646-754-9806 Email: trace.rosel@nyulangone.org

Andrea Thompson, RN Tel: 646-754-1652 Fax: 646-754-9806 Email: andrea.thompson@nyulangone.org

Northwell Health

Address Queens Clinical Center 97-77 Queens Boulevard, 9th Floor Rego Park, NY 11374 718-267-2420

Administrator/Director Lauri Boni Tel: 718-267-2457 Fax: 718-267-2445 Email: lboni@northwell.edu

Primary POC Eduard Yakubov Tel: 718-267-2438 Fax: 718-267-2445 Email: eyakubov3@northwell.edu mailto:linyong.luo@nyulangone.org mailto:wanda.martinez-duperon@nyulangone.org mailto:grace.zheng@nyulangone.org mailto:peter.haugen@nyulangone.org mailto:trace.rosel@nyulangone.org mailto:andrea.thompson@nyulangone.org mailto:lboni@northwell.edu mailto:eyakubov3@northwell.edu

Physical Health POC Charlotte Wihlborg, RN Tel: 718-267-2430 Fax: 718-267-2445 Email: cwihlborg@northwell.edu

Rutgers EOHSI/Rutgers Clinic

Address 170 Frelinghuysen Clinic Piscataway, NJ 08854

Administrator/Director Tracy Reid, MPH Tel: 848-445-0129 Fax: 732-445-0127 Email: tracyb@eohsi.rutgers.edu

Primary POC Joy Clarke Tel: 848-445-6160 Fax: 732-445-0229 Email: jc2899@eohsi.rutgers.edu

Additional POC Brenda Sookhram Tel: 848-445-6160 Fax: 732-445-0127 Email: sookhram@eohsi.rutgers.edu

Mental Health POC Kate York, MSW, LCSW Tel: 848-445-0230 Fax: 732-445-0784 Email: kdesario@eohsi.rutgers.edu

State University of New York, Stony Brook

Address 500 Commack Rd., Suite 204 Commack, NY 11725 (Includes clinics located at Commack and Mineola)

Administrator/Director Julie Broihier Tel: 631-638-0580 Email: Julie.Broihier@stonybrookmedicine.edu

Primary POC Beata Coles Tel: 631-638-0574 Fax: 631-630-6299 Email: Beata.Coles@stonybrookmedicine.edu

Anna Menzies-Tobin Tel: 631-638-0570 Fax: 631-630-6299 Email: Anna.Menzies-Tobin@stonybrookmedicine.edu

Additional POC Priscilla Lara, MHA Tel: 631-638-0726 mailto:cwihlborg@northwell.edu mailto:tracyb@eohsi.rutgers.edu mailto:jc2899@eohsi.rutgers.edu mailto:sookhram@eohsi.rutgers.edu mailto:kdesario@eohsi.rutgers.edu mailto:Julie.Broihier@stonybrookmedicine.edu mailto:Beata.Coles@stonybrookmedicine.edu mailto:Anna.Menzies-Tobin@stonybrookmedicine.edu

Fax: 631-630-6299 Email: Priscilla.Lara@stonybrookmedicine.edu

Jill Jacobson Tel: 631-638-0281 Fax: 631-630-6299 Email: Jill.Jacobson@stonybrookmedicine.edu

Massiel Morillo Tel: 631-638-0282 Fax: 631-630-6299 Email: Massiel.Morillo@stonybrookmedicine.edu

WTC Health Program General Responder Data Center

Address 345 East 102nd Street, Suite 202 New York, NY 10029 Fax: 212-241-7235

Primary POC Tankeesha Williams Tel: 212-241-2614 Email: tankeesha.williams@mssm.edu

Additional Support Points of Contact

Sunitha Rayappa Tel: 212-241-2073 Email: Sunitha.rayappa@mssm.edu

Michelle Mills Tel: 212-241-2749 Email: michelle.mills@mssm.edu

Evelyn Ruiz Tel: 212-241-2749 Email: evelyn.ruiz@mssm.edu mailto:Priscilla.Lara@stonybrookmedicine.edu mailto:Jill.Jacobson@stonybrookmedicine.edu mailto:Massiel.Morillo@stonybrookmedicine.edu mailto:tankeesha.williams@mssm.edu mailto:Sunitha.rayappa@mssm.edu mailto:michelle.mills@mssm.edu mailto:evelyn.ruiz@mssm.edu

Appendix E: Exit Interview

Appendix F: Member Transfer Information Sheet

Translated versions of the Member Transfer Information Sheet can be found on the WTC Health Program website located here: Transferring Clinics - WTC Health Program (cdc.gov).

https://www.cdc.gov/wtc/clinic_transfer.html

Appendix G: Abbreviated Medical Record Transfer Form

Mental Health Addendum May 2025

8/17/2022 Revised 05/14/2025 WTC Health Program

Mental Health Addendum Original Publication August 2022

Revised May 2025 Controlled Unclassified Information

Date of intake assessment

Member and Provider/Requester Information

Member Information

Last First MI

Date of Birth Member #

Primary Language

Circumstances of Living

CCE/NPN Contact Information

Originating CCE/NPN Destination CCE/NPN

Name Name

Phone Phone

Email Email

Transfer Date Initiated

General Information

Special Considerations check all that apply

Urgent Follow-Up (treatment)

Main reason for Transfer Explanation of Other

Mental Health Addendum

Identified Barriers to Care Explanation of Other

Risk Assessment History of Self-Harm Yes No Comments

History of Aggressive and Disruptive Behavior Yes No Comments

Legal History Yes No Comments

Access to Firearm Yes No Comments

Treatment Agreement Yes No Comments

Conditions

WTC-Certified Mental Health Condition(s) check all that apply

Other Mental Health Conditions (if any)

Active Medical Conditions

Current and Past Treatment

2 most recent monitoring exams

Current and Past Treatment Modalities check all that apply

Treatment Type Date(s) of Last Visit

Individual Psychotherapy

Pharmacotherapy

Group

Other

Psychiatric Hospitalizations (Current and Past if Applicable) Date Facility…