Individual & Family Marketplace Plans

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 Baylor Scott & White Health Plan determines medically necessary care cannot be provided by any healthcare provider participating in the Baylor Scott & White Health Plan network, your PCP may refer you to an out-of-network provider.

If Baylor Scott & White Health Plan 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, Baylor Scott & White Health Plan 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?

Good question! Here's what you need to know: a facility-based physician or other healthcare practitioner may not be included in your health benefit plan's provider network. The non-network facility-based physician or other healthcare practitioner may balance bill you for amounts not paid by the health benefit plan; and if you receive a balance bill, you should contact Baylor Scott & White Health Plan.

How can I protect myself from a bill?

• For planned procedures, find out in advance whether your providers are contracted with Baylor Scott & White Health Plan. 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 Baylor Scott & White Health Plan 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 and FairHealthConsumer.org can also help you estimate the prices of various procedures.

Do you need to file a medical claim directly to Baylor Scott & White Health Plan?

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

When seeking care from a provider in the Baylor Scott & White Health Plan network, we don't expect you to pay any more for covered health services beyond the required copayments/coinsurance. If you pay for covered health services in addition to the required copayment(s), you are entitled to reimbursement for such payment if:

• You submit written proof of and claim for payment to Baylor Scott & White Health Plan
• The written proof and claim for payment are acceptable to Baylor Scott & White Health Plan
• Baylor Scott & White Health Plan receives the written proof and claim for payment within sixty (60) days of the date the benefits were received by you.
• You have complied with the terms of the Evidence of Coverage

If you fail to submit written proof of and claim of payment within sixty (60) days, you may still be entitled to reimbursement provided you can document as soon as reasonably possible after the 60-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 844.633.5325 for more information or open a copy of the claim form.

Once you fill out the claim form, mail it to:
Baylor Scott & White Health Plan
ATTN: Pay Me
1206 W. Campus Dr.
Temple, TX 76502

Do you need to file for reimbursement on a prescription pharmacy claim?

• Complete this Member Reimbursement Form and mail in for consideration of coverage.
• Enclose a copy of the pharmacy receipt with your claim submission.

If you disagree with our resolution on your claim, you may appeal our decision. A provider who was not involved in the initial decision will review the appeal.

You may appeal our decision that a service is not medically necessary. A provider who was not involved in the initial decision will review the appeal.

If you are unable to make your monthly premium payment on time, you do have a grace period before losing coverage.

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

• Baylor Scott & White Health Plan coverage will remain in force and will continue to pay claims incurred during the second and third month of the grace period; however, any providers who file claims or who seek preauthorization for benefits to you or your covered dependents will be notified that you have lapsed in payment of premiums.
• If you fail to pay your premium, Baylor Scott & White Health Plan will cancel your coverage retroactive to the last day of the first month of the grace period. Claims incurred during the first month of the grace period will be paid.
• Baylor Scott & White Health Plan shall have no obligation to pay for any benefits provided to you or your dependents on or after the date of termination and you shall be liable to the provider for the cost of those benefits. Baylor Scott & White Health Plam will seek reimbursement from providers for claims incurred during the second and third month of the grace period.

Pharmacy Claim Overview during Grace Period

• If you are in the first month grace period, Baylor Scott & White Health Plan will continue to pay your pharmacy claims.
• If you are in your second or third month grace period Baylor Scott & White Health Plan will not pay pharmacy claims. You will be responsible for 100% of pharmacy costs during the second and third month of the grace period.
• Once you pay back overdue premiums, at your request, Baylor Scott & White Health Plan will reimburse you 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.

A previously paid claim can be reversed by Baylor Scott & White Health Plan — this is a retroactive denial.

When Baylor Scott & White Health Plan retroactively denies a claim, you will be responsible for payment on the claim to the provider. To prevent retroactive denials, you can:

1. Make sure you receive prior authorization on any service requiring it before getting care. Find out more by talking to your physician.
2. Provide Baylor Scott & White Health Plan 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.

If you have any questions, please contact Baylor Scott & White Health Plan Customer Service at 844.633.5325.

Do you think that you may have overpaid on your monthly premium invoice? If so, please let us know. Simply call Baylor Scott & White Health Plan Customer Service at 844.633.5325 and we'll assist you.

If we find that you are due a refund 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 are due a full refund, and pay your monthly bill by auto draft or electronic funds transfer (EFT) using a bank account or credit card, we will credit your account. If you are owed a partial refund payment, Baylor Scott & White Health Plan will mail you a refund check instead. In either case, you should receive a refund within 7-10 business days from the date the refund is approved.

Medically necessary care is healthcare resulting from an illness or injury, and, for some services, requires prior authorization by Baylor Scott & White Health Plan.

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 three (3) calendar days before you receive them.

A decision on a request for prior authorization for medical services will typically be made within 72 hours of us receiving the request for urgent cases or 15 days for non-urgent cases.

For a listing of services requiring prior authorization, please contact Customer Service at 844.633.5325. A paper copy is available upon request.

Note: This listing is subject to change.

Information about pharmacy benefit drug prior authorizations.

Inpatient or outpatient? This hospital or that one? Part of getting the right care is making sure you're in the right place, and that's what our Concurrent Review process is about.

When you are in the hospital, our Utilization Management (UM) staff of licensed nurses and medical doctors 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 Baylor Scott & White Health Plan 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.

The drugs you need may not be listed on our formulary. If that is the case, you or your provider can submit a formulary exception request to get a coverage determination.

Requests can be submitted online, or by phone, fax or mail. For more info, visit us on our pharmacy information page.

The medication you seek an exception for will initially be reviewed by our pharmacy benefit manager, OptumRx.

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 emergency 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:

• External Review - Formulary Exception Form

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 healthcare items and services, and the experimental or investigational nature of healthcare items and services for an enrollee.

To request an expedited external review for exigent circumstance, indicate the request is for urgent care on the Request Form or verbally if initiating the request by phone.

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.

An Explanation of Benefits (EOB) is a form that we will send you after you or a covered family member gets healthcare services. After receiving covered health services, an EOB will show you what was billed and what Baylor Scott & White Health Plan paid.

The EOB is one way Baylor Scott & White Health Plan helps keep you in the driver's seat.

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

• View a Sample 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 member portal
• 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 number of the EOB you're looking for
• The EOB displays on a separate browser tab
• The EOB can be printed or downloaded

Whether you have coverage through a parent or spouse, or you are on Medicare, we know we may not be your only health insurer. The coordination of benefits process 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.

We'll send you a letter from time to time asking if you have any additional coverage, and it is important that you respond so that we can keep our information up to date. 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:

Baylor Scott & White Health Plan
1206 W. Campus Drive
Temple, TX 76502

You can also call our Marketplace Customer Service number at 844.633.5325.