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Frequently Asked Questions

Accessing Care How do I obtain emergency care? When should I call 911 instead? How do I obtain primary care services? How do I obtain specialty care, behavioral health care services, and hospital services? How do I get care after normal office hours? W hat does "Open Access HMO" mean?

Benefits What beneﬁts and services are included and excluded from my coverage? How can I ﬁnd my copays and other charges for which I am responsible? What beneﬁt restrictions apply to services obtained outside SWHP's system or service area? What does "not mutually exclusive" mean?

Claims How do I submit a claim for covered services? What should I do if I get a bill that should have been paid by SWHP?

Customer Service How can I obtain language assistance? How do I voice a complaint? How do I appeal a decision that adversely affects coverage, benefits, or my relationship with the organization?

Miscellaneous How can I add or delete someone from coverage under my plan? What if I need additional identification cards, a copy of my policy, or any other materials? How does SWHP evaluate new technology for inclusion as a covered beneﬁt?

Out-of-Network How do I obtain care and coverage when I am out of SWHP's service area? What kind of coverage will my college-age child have while he or she is away at school? I am currently seeing a doctor outside of SWHP; can I continue to see that doctor? How do I get a referral outside the SWHP network when you cannot provide the services that I need? What happens if I am hospitalized outside the service area?

Pharmacy What are your pharmaceutical management procedures?

Providers How do I obtain information about participating practitioners and providers? If I decide I want to designate a primary care physician (PCP), how do I select a PCP and what happens if I do not like him/her after I have made a decision? Is it necessary that all our family members use a PCP/the same PCP?

Accessing Care

How do I obtain emergency care? When should I call 911 instead? SWHP will provide benefits for medically necessary emergency care whether you are temporarily out of the service area or within the service area. Emergency care is defined as the sudden and unexpected onset of a condition of such a nature that a prudent layperson, possessing an average knowledge of medicine and health, believes their health could be jeopardized if they do not get immediate treatment. SWHP will approve or deny the requested post-stabilization treatment within one hour if contacted by the provider or facility. Some examples of emergency conditions include the following.

Unusual or excessive bleeding
Broken bone
Acute abdominal or chest pain
Loss of consciousness
Suspected heart attack
Sudden persistent pain
Serious burn
Poisoning
Convulsions
Difficulty in breathing

In all emergency situations, you are encouraged to seek care with the nearest SWHP approved provider; however, if the time needed to reach a SWHP approved provider might endanger your health, go to the nearest emergency room. Medically necessary emergency care is covered. If you are hospitalized as a result of the emergency, you should contact the SWHP Health Services Division within 24 - 48 hours of any admission at (888) 316-7947. Coverage for continued treatment is assured when approval is obtained from the SWHP Medical Director through the Health Services Division. Emergency care in a hospital emergency room requires a copay, which will be waived if hospital admission occurs within 24 hours.

While a medical emergency is considered a life-threatening condition, urgent care is considered less severe than an emergency, but requiring care more quickly than elective care. Urgent care includes, but is not limited to, sudden illnesses and injuries, lacerations, and fever. SWHP encourages you to access one of its Urgent Care Clinics if you find yourself needing urgent care after hours. If you do not know when to access an Urgent Care Clinic, please contact a SWHP nurse through our nurse advice line at (877) 505-7947.

How do I obtain primary care services? To make a routine appointment, contact your physician's office. To help the staff schedule your appointment quickly, please refer to the following.

If it is your first appointment, indicate this to the appointment clerk.
Have your identification card ready for any required information.
Periodic examinations (e g., annual pap smears or history and physical) may need to be scheduled 8 -12 weeks in advance. Other routine appointments are scheduled according to the urgency of the problem.
Notify your physician's office as quickly as possible if you cannot keep an appointment.

You may access any of our contracted physicians. Your copay is based on whether the physician is a primary care physician or specialist. PCPs include:

Family Practice treats all age groups from newborns to the elderly. They provide routine medical care, referrals to specialists, some minor surgical procedures, and obstetrics/gynecology services.
Community Internal Medicine physicians treat patients 16 years and older. They provide routine medical care, gynecology services, and referrals to specialists.
Pediatrics treats children up to age 18 and provides routine care as well as referrals to specialists.
OB/GYN specializes in women's health and family planning.

For a list of physicians visit the Find A Provider or call Customer Service toll-free at (800) 321-7947 or (254) 298-3000.

How do I obtain specialty care, behavioral health care services, and hospital services? All non-emergent medical care must be provided by SWHP network providers. You may see a network specialist without a referral. Behavioral health services and elective hospital admissions require prior authorization through SWHP Care Coordination Department.

How do I get care after normal office hours? After-hours telephone calls or emergency requests are routed to the Scott & White Memorial Hospital operator. The Health Services Department is contacted for authorizations for in-patient admissions and emergency surgeries and procedures.

If you are enrolled in Scott and White Health Plan and are ill or injured, you can contact the Nurse Advice Line at (877) 505-7947. The Nurse Advice Line is staffed 24 hours a day, every day of the year. Our nurses can give you information about how to take care of yourself at home or can help determine if an office visit, an urgent care visit, or an emergency room visit is most appropriate for your symptoms. It is free, completely voluntary, and confidential. However, this service is not meant to replace a doctor's care.

What does "Open Access HMO" mean? Scott and White is now an Open Access HMO. This means that a member can go to any network provider without a referral. Members may choose a network primary care physician (PCP) if they would like to designate one, but PCPs are no longer required by the Scott and White Health Plan.

Benefits

What beneﬁts and services are included and excluded from my coverage? You may check your benefits by logging in to the 'MyBenefits' page from the top right corner of the website. Select 'My Information', 'Member Detail', then the 'Policy Benefit Name' link. You will be able to view a PDF of your benefits and exclusions. You may also call our Customer Service department at (800) 321-7947 or (254) 298-3000.

How can I ﬁnd my copays and other charges for which I am responsible? You may check your copays and other charges by logging in to 'MyBenefits' from the top right corner of the website. Select 'My Information', 'Member Detail', then the 'Policy Benefit Name' link. You will be able to view a PDF of your copays, benefits, and exclusions. You may also call our Customer Service department at (800) 321-7947 or (254) 298-3000.

What beneﬁt restrictions apply to services obtained outside SWHP's system or service area? You may view benefit restrictions by logging in to 'MyBenefits' from the top right corner of the website. Select 'My Information', 'Member Detail', then the 'Policy Benefit Name' link. You will be able to view your Evidence of Coverage (EOC), which lists restrictions in your plan. You may also call our Customer Service department at (800) 321-7947 or (254) 298-3000.

What does "not mutually exclusive" mean? Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a Participant’s total out-of-pocket maximum could contain a combination of coinsurance and/or co-payments. (For example, a Participant could pay up to $6,450 in co-payments alone if there was no coinsurance paid throughout the year. If a Participant met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,450 in co-payments, totaling $6,450 in overall out-of-pocket expense.)

Claims

How do I submit a claim for covered services?

You must access services through a Scott and White network provider unless you have received prior authorization through SWHP Health Services Division. For covered services provided by SWHP network providers, members do not have to file a claim. The participating provider will file the claims on your behalf. Just make sure you present your ID Card at the time of service which identifies you as a member.

For services provided by non-participating providers, you will need to file a claim for reimbursement directly to SWHP at the following address:

Scott and White Health Plan Attn: Claims Dept. 1206 West Campus Drive Temple, TX 76502

Once the Health Plan receives your claim, you will receive an acknowledgement letter within 15 days. The acknowledgment letter will indicate if any additional information is needed.

What should I do if I get a bill that should have been paid by SWHP? As soon as you receive the bill, please contact a SWHP Claims Representative at a SWHP office near you for assistance.

Customer Service

How can I obtain language assistance? In an effort to improve communication with non-English speaking members, SWHP uses the interpretive services of AT&T. When calling a SWHP representative, you can request to be linked to a highly trained interpreter. Let the Customer Service Advocate know your primary language and the call will be completed with the help of an AT&T interpreter. You do not have to call a special line for this service.

SWHP also has several interpreters available through Customer Service at (800)-321-7947.

How do I voice a complaint? SWHP is dedicated to addressing your grievances and resolving them promptly. If there is ever a time when you are not satisfied with the performance of SWHP or one of its providers, you should contact a Customer Service Advocate at (800) 321-7947 immediately. All grievances are documented and thoroughly investigated. SWHP encourages your input and will not discriminate against you, refuse coverage, or engage in any other retaliation if you choose to file a complaint or request an appeal of a decision.

SWHP's definition of a complaint is an oral or written form of dissatisfaction that is not able to be resolved promptly to your satisfaction. When you call a Customer Service Advocate to express dissatisfaction, he/she will immediately document your issues and send you a complaint form (as required by the Texas Department of Insurance) to complete and send back to SWHP. This form does not go into your medical record; it simply helps SWHP address your complaint with the appropriate person or department. SWHP responds to the oral and written complaints in the same manner and informs you of a resolution within 30 calendar days of receipt of the complaint. Read our Complaint and Appeal Procedures.

How do I appeal a decision that adversely affects coverage, benefits, or my relationship with the organization? SWHP's definition of an appeal is a request for SWHP to reverse a previous adverse decision. All appeals are presented to a panel, which is held within 30 calendar days after receipt of the request. You have the right to appear before the panel and to present written or oral information in support of your request to reverse the previous decision. The SWHP will permit and pay for an immediate appeal to an independent review organization in the event the decision rendered was an Adverse Determination (denial of coverage based on medical necessity determination) to the complainant and the request was presented to the SWHP within 180 days of the previous decision. For more information on your appeal rights, please contact a Customer Service Advocate at (800) 321-7947. Read our Complaint and Appeal Procedures.

Miscellaneous

How can I add or delete someone from coverage under my plan? If you are an active employee, contact your Benefits Coordinator. If you are a retiree, please contact the Employees Retirement System toll-free at (877) 275-4377.

What if I need additional identification cards, a copy of my policy, or any other materials? You may request an identification card online. To receive a copy of your policy, identification cards, summaries of benefits, or any other material, you may also contact a Customer Service Advocate at (800) 321-7947.

How does SWHP evaluate new technology for inclusion as a covered beneﬁt? SWHP has a process whereby a group of physicians and other health care professionals evaluate requests for coverage of new technological procedures or treatments. The Technical Assessment Committee receives from a requesting doctor, a proposal to SWHP that outlines a new or currently uncovered medical or behavioral procedure, devices or treatments, the perceived advantages over current therapy, criteria for utilization, and supporting papers from peer-reviewed scientific journals.

The Technical Assessment Committee then meets to evaluate the physician's request for coverage. The recommendations of the Technical Assessment Committee are presented to the SWHP Quality Improvement Committee for a final approval determination. If you have a request for coverage of a new medical or behavioral procedure, device, or treatment, please contact your physician or the Health Services Division at (888) 316-7947.

Out-of-Network

How do I obtain care and coverage when I am out of SWHP's service area? As a member of SWHP, you are covered worldwide for any true emergency that occurs. Incidents such as heart attacks, deep lacerations, loss of consciousness, breathing difficulties, broken bones, and other critical conditions that require immediate treatment are covered with your emergency room copay/coinsurance. If you have a medical problem that is urgent but is not an emergency, you are encouraged to contact our Nurse Advice Line at (877) 505-7947. This is a 24-hour line that you can access from anywhere in the world for medical advice and assistance in managing your illness.

When seeking treatment in an out-of-network emergency room, provide your member identification card. This will speed up the processing and payment of your bill by SWHP. This will also allow the treating physician to discuss your emergency care with your network physician, if necessary.

What kind of coverage will my college-age child have while he or she is away at school? SWHP will cover any emergency that occurs while away at school. It will be important to plan for routine medical needs while the student is away. If your child is attending school within the State and will be located near one of our provider clinics, your child can receive care at the facility. If the student is attending school out of the SWHP service area, it may be necessary to consider supplementary coverage for routine medical care. The student may want to use the college dispensary for his/her routine medical care. The student can also access our Nurse Advice Line at (877) 505-7947 at any time for medical advice and assistance.

I am currently seeing a doctor outside of SWHP; can I continue to see that doctor? SWHP is a Health Maintenance Organization (HMO), and your care has been prepaid and prearranged for within the SWHP network. If you would like SWHP to pay for the doctor visit, you must see a SWHP physician. You may continue to see the physician outside the SWHP network, but SWHP will not pay for the visit. You may want to get copies of your medical care records from the outside doctor so that your SWHP physician can continue care.

How do I get a referral outside the SWHP network when you cannot provide the services that I need? SWHP network is a large, multi-specialty network and, in most cases, can meet the majority of your medical needs. If you develop a medical condition that your Scott & White physicians cannot care for, you will need a recommendation from your SWHP network physician and the approval of the SWHP Medical Director before any out-of-plan services can be covered. A formal review of your case will be provided and you will receive a letter outlining clearly what SWHP will or will not cover with the outside physician.

For more information on referrals, see the Referrals and Prior Authorizations page.

What happens if I am hospitalized outside the service area? Please have someone call SWHP within 24-48 hours of your admission so that we can begin coordinating your care as soon as possible. The instructions for reporting an out-of-plan admission are printed on the back of your member identification card. Simply use the toll-free line.

If you are hospitalized while traveling with others, we suggest that you always have someone else within your group know what to do in case you are unable to speak for yourself.

Pharmacy

What are your pharmaceutical management procedures? Our procedures describe the method for managing the drug formulary (drug listing) in order to provide the most cost-effective therapy options.

Prior Authorization: Scott and White Health Plan may require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Scott and White Health Plan before you fill your prescriptions.

Quantity Limits: For certain drugs, Scott and White Health Plan limits the amount of the drug that Scott and White Health Plan will cover. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Scott and White Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Scott and White Health Plan may not cover drug B unless you try Drug A first. If Drug A does not work for you, Scott and White Health Plan will then cover Drug B.

Prescriptions have copays (after the $50 per person deductible):

A = Tier 1 Generic copay (preferred generic) B = Tier 2 Preferred brand-name copay C = Tier 3 Nonpreferred brand-name copay

Excluded drugs are not covered. For example, a drug used for cosmetic purposes may be considered an excluded drug. Please review your Evidence of Coverage and other plan materials to determine which drugs may be considered excluded from coverage.

You can find our drug list on the ERS formulary. You can find out if your drug has any additional requirements or limits by looking at our drug list. For more detailed information about your Scott and White Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have any questions about Scott and White Health Plan, please call our Customer Service at (800) 321-7947 or (254) 298-3000.

Providers

How do I obtain information about participating practitioners and providers? If you would like to know the professional qualifications of a SWHP network physician, contact a Customer Service Advocate at a SWHP office near you or click Find A Provider. You can inquire about your physician's medical school, residency, board certification status, and any other information you may need to choose a practitioner in the network.

If I decide I want to designate a primary care physician (PCP), how do I select a primary care physician (PCP)? Scott and White is an Open Access HMO. A member can go to any network provider without a referral. Members may choose a network primary care physician (PCP) if they would like to designate one, but PCPs are no longer required by the Scott and White Health Plan.

If you would like to select a PCP, please refer to our online directory. Each person listed on your plan may select a PCP from the following physicians:

Family Practice treats all age groups from newborns to the elderly. They provide routine medical care, referrals to specialists, some minor surgical procedures, and obstetrics/gynecology services.
Community Internal Medicine physicians treat patients 16 years and older. They provide routine medical care, gynecology services, and referrals to specialists.
Pediatrics treats children up to age 18 and provides routine care as well as referrals to specialists.
OB/GYN for women's health and family planning.

When selecting a PCP, consider which clinic would be most convenient to meet your own needs. Each person listed on your plan can select his or her own doctor.

If you would like specific information about any of the PCPs, just contact your Customer Service Advocate at a Scott and White Health Plan (SWHP) office near you. Once you designate a PCP, you can make an appointment with that physician. If your PCP is unavailable, you can see any other physicians of the same specialty that work with the clinic.

You may also select or change your PCP online.

What if I do not like my PCP after I have designated him or her? You can change your PCP anytime, online or by contacting your Customer Service Advocate at a SWHP office near you.

Do all family members need to use a PCP/or the same PCP? No covered person is required to designate a PCP. If they wish to do so, each person listed on your plan can select his or her own doctor.