Scott & White Health Plan

Referrals and Prior Authorizations Under the Medical Plan

Except for Emergency Care Services, Scott & White Health Plan network providers must provide all services under your Evidence of Coverage. Most services are available through Scott & White Health Plan network providers and only require coordination of the referral through your primary care physician (PCP) to other Scott & White Health Plan network providers. No authorization through the Health Services Division (HSD) of Scott & White Health Plan is required for these basic service referrals in-network. An occasional service requires notification from your PCP to the Plan, which they will handle for you. Scott & White Health Plan provides coverage for these services coordinated through your PCP under the terms of your specific Evidence of Coverage.

When a service requires prior authorization through the HSD, it is usually due to a service having a limited benefit, being an out-of-network referral for services, and/or a service that may potentially be a non-covered benefit under the “Exclusions and Limitations” section of your Evidence of Coverage. These service requests are required to be submitted by your PCP and/or Plan Specialist to the Plan in advance of receiving the service in order to receive an individual case review and coverage determination by the Plan Medical Directors. If you seek these types of services without the required prior approval coverage determination, you may be at risk for all charges associated with the service. (Examples include, but are not limited to: Plastic Surgery; Dental/Oral Surgery; Transplants; non-urgent/emergent transports; all out-of-network services; etc.)

If you and/or your physician have a question as to whether a service requires prior authorization through the HSD, you may contact your Scott & White Health Plan Customer Service Coordinator. If a referral has been submitted to the HSD through the prior authorization process, you may check that it has been received by calling the Customer Service Coordinator and/or by calling the HSD at (888) 316-7947. Determinations are made as quickly as possible within Texas Department of Insurance time regulations, but require your physicians and/or providers to submit all information needed to make the determination. Once a decision has been rendered, the HSD will attempt to reach you and your physician(s) and/or providers three times to deliver a verbal authorization determination. If the service is denied for any reason, you will be provided your complaint/appeal rights and information on how to access the process. You will also receive in the mail a letter outlining the coverage determination and the complaint/appeal process, if applicable.