Member Resources

Any contracted BSWHP provider can provide telemedicine medical services and/or telehealth services, for certain circumstances and conditions, to a BSWHP member.

• No pre-authorization is required by an in-network BSWHP provider. However, if an out-of-network provider is needed, pre-authorization is required. In these cases, BSWHP requires a 48-hour advance notice prior to the member receiving telemedicine services from an out-of-network provider.
• Covered services are subject to all applicable copayments, coinsurance and deductible amounts, not exceeding those for the same covered service provided in an in-person location such as a doctor's office, clinic or hospital.

If you have any questions, contact the Plan Customer Service at the number on the back of your BSWHP member ID card.

BSWHP is a State of Texas not-for-profit company, organized for the purpose of operating an Independent Practice Association (IPA)-model health maintenance organization. BSWHP provides prepaid medical, hospital and related comprehensive healthcare services to HMO subscribers and their enrolled dependents within our approved service area.

BSWHP does not employ incentives to encourage barriers to care and services, specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care, or provide incentives for utilization review decision makers that result in underutilization. Utilization management decision-making is based only on the appropriateness of care and service and the existence of coverage.

Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is "balance billing" (sometimes called "surprise billing")?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn't in your health plan's network.

"Out-of-network" describes providers and facilities that haven't signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharing amount (such as copayments and coinsurance). You can't be balance billed for these emergency services. This includes services you may get after you're in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You're never required to give up your protections from balance billing. You also aren't required to get care out-of-network. You can choose a provider or facility in your plan's network.

When balance billing isn't allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you've been wrongly billed, you may contact the No Surprises Helpdesk at 800.985.3059.

Visit www.cms.gov./nosurprises for more information about your rights under federal law.

Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information to initiate the prior authorization review process:

Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted. To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests) or similar medical record documentation to illustrate medical necessity.

When BSWH receives a request for prior authorization and the request does not contain complete clinical documentation and/or information: