Important Plan Information

 

• You may have to use an out-of-network provider for emergency or out-of-area urgent care services.
• If FirstCare determines medically necessary care cannot be provided by any health care provider participating in the FirstCare network, your PCP may refer you to an ount-of-network provider. 

If FirstCare approves a referral for out‐of‐network services because no network physician or provider is available, or if you have received out‐of‐network emergency care, FirstCare will, in most cases, resolve the out‐of‐network physician's or provider's bill so that you only have to pay any applicable in‐network copayment, coinsurance, and deductible amounts.

What is balance billing?

A facility-based physician or other health care practitioner may not be included in your health benefit plan's provider network. The non-network facility-based physician or other health care practitioner may balance bill you for amounts not paid by the health benefit plan; and if you receive a balance bill, you should contact FirstCare.

How can I protect myself from a bill?

• For planned procedures, find out in advance whether your providers are contracted with FirstCare. This is especially important in the case of facility-based providers, such as radiologists, anesthesiologists, pathologists, and neonatologists.
  • NOTE:  Even if a hospital is in our network, there may be doctors and laboratories providing services at that hospital who might not be.
• Review your plan documents and/or call FirstCare to make sure the services you will get are covered under your policy. If the services are not covered, you will have to pay the charges.
• Shop around. TDI's Health Insurance Reimbursement Rates Consumer Information Guide lists average costs for common medical procedures in different regions of Texas. Websites such as NewChoicehealth.com, FairHealthConsumer.org and TxPricePoint.org can also help you estimate the prices of various procedures.

FirstCare does not expect you to make payment for covered health services, beyond the required copayments/coinsurance, when seeking care from a FirstCare network provider. However, if you pay for covered health services in addition to the required copayment(s), you must file a claim with FirstCare within 180 days from the date you received those covered health services, unless you can document as soon as reasonably possible after the 180-day period good cause why the claim could not be filed within this time period.   
 
You can obtain forms for the submission of written proof of payment by contacting our Customer Service Department at 1.855.572.7238 for more information or click here for a copy of the claim form.

Once you fill out the claim form, mail it to:

 
If you disagree with our resolution, you may appeal our decision. A panel of staff members, physicians or other providers, and FirstCare members will hear the appeal. You may appear in person before the appeal panel and present evidence.
 
You may appeal our decision that a service is not medically necessary. A provider who was not involved in the initial decision will review our decision. 
 

Members with tax credit:

If you are receiving a premium tax credit under the Affordable Care Act, you have a three-month grace period for paying premiums. If full payment of the premium is not made within the three month grace period, then coverage will retroactively terminate on the last day of the first month of the three-month grace period.

Members without tax credit:

If you are not receiving a premium tax credit, you have a 31 day grace period for paying premiums. If full payment of the premium is not made within the 31 day grace period, then coverage will automatically terminate on the last day of the coverage period for which premiums have been paid. 

 
When FirstCare retroactively denies a claim, you would then become responsible for payment on the claim to the provider. To prevent retroactive denials, you can:

1. Make sure you get prior authorization on any service requiring it before getting care. Find out more by talking to your physician.
2. Provide FirstCare with updated information on any other health insurance you may have so we can coordinate payment with the other insurance company. 
3. Pay your premiums on time. Your monthly invoice lists the date payment is due. You can also set up automatic monthly premium payments. Click here for more details. 

If you have any questions, please contact FirstCare Customer Service at 1.855.572.7238.

If you find that your monthly invoice is a higher dollar amount than expected, or if you think you might have overpaid your monthly premium, simply call FirstCare Customer Service at 1.855.572.7238, and we will assist you.

Are you due a refund? If so, and you pay your monthly bill by check, we will mail you a refund check. You should receive it within 7-10 business days from the date the refund is approved. 

If you pay your monthly bill by auto draft or electronic funds transfer (EFT) using a bank account or credit card, we will credit your account. However, if it is a partial refund payment, FirstCare will mail you a refund check. In either case, you should receive refund within 7-10 business days from the date the refund is approved.  

 

We require that certain medical services, care, or treatments be preauthorized before we will pay for all related covered health services. Prior authorization means that we review in advance and confirm that proposed services, care, or treatments are medically necessary. If you fail to get proper authorization on the services, care or treatment that require preauthorization, they will not be covered.You are responsible for ensuring that your doctor obtains prior authorization for any proposed services at least five (5) days before you receive them. 

For a listing of services requiring prior authorization, please click here or contact Customer Service at 1.855.572.7238. A paper copy is available upon request.  
 

 
When you are in the hospital, our Utilization Management (UM) staff reviews information about your care that is provided by the hospital. We use this information to determine whether the inpatient setting is right for your condition and to make sure that you are in the hospital for the right length of time to treat your condition. If you are outside of the FirstCare network, we also need to make sure that either your care is an emergency or that you could not have gotten your care within the network. 

These reviews are carried out by licensed nurses and medical doctors.

 

How do I request an exception?

Members or physicians can ask FirstCare to make an exception to our coverage rules. There are two types of exceptions:

• When a drug is not covered on the formulary, a request can be submitted to cover a medication that is not on our formulary.
• When there are needs outside of our coverage rules (e.g., Step Edits or Quantify Limits), a request can be made to waive coverage restrictions. For example, FirstCare may limit the amount that can be dispensed per fill and/or per month for specific drug(s), you or your doctor can ask to waive the limitation and dispense a higher quantity.

To obtain a copay exception form please contact the customer service phone number in the back of FirstCare’s member ID card. Exceptions are reviewed for medical necessity, your inability to use covered drugs (e.g., side effects), current covered products may not be effective for you, and new drug entrants that have not yet been reviewed and placed on the formulary. Reviews will consider superiority of the request over current covered options.

Exception requests can be submitted by making the request to FirstCare via:

1. Completing the Exception Form http://www.firstcare.com/en/Individuals-and-Families/Marketplace-Plans/Pharmacy-Drugs/Drug-Lists-Benefit-Forms
2. By calling the Customer Service phone number listed on the back of your ID card.

Exception Coverage Determination Timeframes

• Standard Exception - No later than 72 hours following receipt of request.
• Expedited Exception – No later than 24 hours following receipt of request.

An Explanation of Benefits (EOB) is a form that we will send you after you or a covered family member gets health care services. The EOB is one way FirstCare helps you manage your health care and control costs.

Carefully read and review any EOB you receive. It provides a list of services that your medical provider or supplier claims to have provided to you. Simple errors can often be corrected by contacting the provider and/or health insurer's customer service department. However, if the EOB contains inaccuracies or discrepancies that cause you to question whether an honest claim for payment has been submitted, you should contact our Special Investigations Unit (SIU) to report this information:  1.800.718.5205, or write to FirstCare Health Plans, Compliance Department, Attn: SIU Investigator, 12940 N. Hwy 183, Austin, Texas, 78750.

 Click here to view a sample FirstCare EOB.
 

Access your EOB online

• Log on to FirstCare's Member Self-Service portal
• Click on the Plan Benefits tab
• Click on the Claims tab—located in the section below your contact details
• Under the View EOB column, click on the link(s) provided to open a PDF of the EOB you wish to view

Coordination of benefits is the way to determine the primary payor for an insurance claim when coverage by two or more health insurance plans are in effect at the time a medical claim is filed.
 

Update your information to process claims faster

Have you recently added a second insurance plan? Fill out the other insurance survey form and mail it to: FirstCare Health Plans, P.O. Box 853935, Richardson, Texas 75085-3935. You can also call our Marketplace Customer Service number at 1.855.572.7238.