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Individuals and Families / Marketplace Plans / Important Plan Information

Important Plan Information

We know that health insurance can be confusing, so we've gathered information on the topics listed below to help explain FirstCare's payment policies and other important aspects of your Marketplace plan coverage.

Click on any of the topics below for more details.

Out-of-Network Liability & Balance Billing

Your plan provides no benefits for services you receive from out‐of‐network physicians or providers, with specific exceptions as described in your Evidence of Coverage and below .

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 out-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 rates.texashealthcarecosts.org 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.

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Member Claim Submissions

Do you need to file a claim directly to FirstCare?

Did you pay for covered health services over the required copayment/coinsurance?

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.

Note: Reimbursement will not be allowed if a claim is made beyond one year from the date of service the covered health services were first acquired.

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:

FirstCare Health Plans

P.O. Box 211342

Eagan, MN 55121

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Filing an Appeal

Did you disagree with our resolution on your claim?

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.

As of January 1, 2020, appeal requests for drugs obtained under the Pharmacy benefit are processed by OptumRx. To request a drug coverage appeal for a Pharmacy benefit drug, submit the request to OptumRx. For information regarding how to submit a drug coverage request, refer to the table below.

Appeals (Redeterminations)
FAX	1-877-239-4565
PHONE	1-888-403-3398
MAIL	OptumRx Prior Authorization Department c/o Appeals Coordinator P.O. Box 25184 Santa Ana, CA 92799

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Grace Periods & Pending Claims

If you are unable to make your monthly premium payment on time.

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.

Medical Claim Overview during Grace Period

FirstCare will pay provider’s medical claims on members who are within the three month grace period.
If the member fails to pay their premium, FirstCare will cancel the member’s coverage retroactive to the last day of the first month of the grace period and seek recovery of payment for services received in the second and third months of the grace period from the provider.

Pharmacy Claim Overview during Grace Period

FirstCare will pay pharmacy claims on members who are within the first month grace period.
FirstCare will not pay pharmacy claims on members who are in the second or third month grace period. Members will be responsible for 100% of pharmacy costs during the second and third month of the grace period.
Once members pay back overdue premiums, at the Member’s request, FirstCare will reimburse the Member for the covered expense according to the enrolled plan benefits.

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.

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Retroactive Denials

A previously paid claim can be reversed by FirstCare—this is a retroactive denial.

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:

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

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

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Member Recoupment of Overpayments

Did you overpay on your monthly premium invoice? If so, let us know.

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.

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Medical Necessity & Prior Authorizations

Medically necessary care is health care resulting from an illness or injury, and, for some services, requires prior authorization by FirstCare.

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 contact Customer Service at 1.855.572.7238. A paper copy is available upon request.

Note: This listing is subject to change.

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Concurrent Review

This review helps us ensure you are receiving the right care, in the right setting, for your condition.

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.

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Drug Exception Timeframes & Enrollee Responsibilities (not required for SADPs)

Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list).

These medications are initially reviewed by the pharmacy benefit manager (OptumRx) through the formulary exception review process. The member or provider can submit the request online, or by phone, fax, or mail. To access the online portal, pharmacy formulary exception request form, phone numbers, or fax numbers click here.

Initial requests for formulary exception are reviewed within 24 hours for expedited requests and 72 hours for standard requests. To request an expedited review for exigent circumstances, indicate that you need an expedited or urgent review on the request form or verbally if initiating the request via phone. If the drug is denied, you have the right to an external review.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case to an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision.

An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing the request:

HHS Federal External Review Request Form

Maximus Federal Services

3750 Monroe Avenue, Suite 705

Pittsford, NY 14534

Ferp@Maximus.com

Note: The Member or the Member’s legal guardian must sign the consent to release medical information to the IRO (included as part of IRO form).
The URA will comply with the Independent Review Organization’s determination with respect to the medical necessity or appropriateness of health care items and services, and the experimental or investigational nature of health care items and services for an enrollee.

To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form or by contacting MAXIMUS Federal Services directly by phone 1-888-866-6205 or by fax 1-888-866-6190.

You can ask for an expedited internal appeal and an expedited external review at the same time, if the timeframe for an expedited internal appeal would place your life, health or ability to regain maximum function in danger.

For standard exception review of medical requests where request was denied, the timeframe for review is 72 hours from when we receive the request.

For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.

To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form.

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Explanation of Benefits (EOBs)

After receiving covered health services, an EOB will show you what was billed and what FirstCare paid.

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: 1.866.399.8161, e-mail at SWHPComplianceDepartment@bswhealth.org, 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.

Note: This is not an actual EOB and may be different from the one you receive from us.

Access your EOB online

Go to the My BSW Health Member Self Service portal
On the left-hand menu bar, select “Insurance and Billing”.
Next select the Health Plan (“FirstCare Health Plan” or Scott & White Health Plan”).
Next select “Claims”.
On the ‘Claims’ page, insure that the date range includes the start date of the service of the EOB you’re looking for.
Click the Claim umber of the EOB you’re looking for.
The EOB displays on a separate browser tab.
The EOB can be printed or downloaded.

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Coordination of Benefits (COB)

How to understand who pays your claim first.

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

Coordinating your benefits helps FirstCare process your claims faster—maximizing your benefits—and can possibly lower your out-of-pocket costs too.

It’s important that we keep your information up-to-date. We’ll send you a letter from time to time asking if you have any additional coverage. Please respond to that letter. If we don’t receive your response within 45 days, and we believe you have secondary coverage, we may start rejecting your claims.

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 211342, Eagan, MN 55121-1342. You can also call our Marketplace Customer Service number at 1.855.572.7238.

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Questions? Contact Us!

If you have any questions about your plan, your benefits, or FirstCare—our Customer Service team is standing by, ready to assist you.

Please call us at 1-855-572-7238, Monday through Friday, 8 a.m. - 5 p.m. CT

For details on information in other languages, click here.

Member Portal

FirstCare is here for you.

Interested in a Marketplace plan? Contact us today at 1-866-522-2516.

Already a member? Call Customer Service at 1-855-572-7238.

Resources

FirstCare's Direct Enrollment Portal Service Area Map Find a Provider 2020 Get a Quote Pay Your Premium Rate Increase Justification (2019)

Non-Discrimination Notice

FirstCare does not discriminate or exclude people based on race, color, national origin, age, disability, or sex. Read more here.

Access a Doctor, 24/7/365

FirstCare Virtual Care—powered by MDLIVE lets you connect with a doctor from wherever you are. For more details, click here.

Talk to a Nurse—Nurse24™

Need care advice? Should you see a doctor? Get the info you need today! FirstCare members can talk to a nurse 24/7 by calling 1-855-828-1013 to get answers 24 hours a day, 7 days a week! TTY users can call 7-1-1 or 1-800-955-8771. Voice communication is available at 1-800-955-8770.

Utilization Management

Ever wonder how we decide what services to authorize for our members? Our utilization management (UM) decisions are based on medical evidence and consensus of health care professionals. For more details, click here.

Note: FirstCare Health Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

Important Plan Information

Out-of-Network Liability & Balance Billing

What is balance billing?

How can I protect myself from a bill?

Member Claim Submissions

Filing an Appeal

Grace Periods & Pending Claims

Members with tax credit:

Members without tax credit:

Retroactive Denials

Member Recoupment of Overpayments

Medical Necessity & Prior Authorizations

Concurrent Review

Drug Exception Timeframes & Enrollee Responsibilities (not required for SADPs)

Explanation of Benefits (EOBs)

Access your EOB online

Coordination of Benefits (COB)

Update your information to process claims faster

Questions? Contact Us!

Member Portal

FirstCare is here for you.

Resources

Non-Discrimination Notice

Access a Doctor, 24/7/365

Talk to a Nurse—Nurse24™

Utilization Management

Related Documents

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