Important Plan Information

 
For example, if you go to an in-network hospital for emergency care and are treated by an out-of-network doctor, the in-network hospital can only bill you for copays, deductibles, and coinsurance amounts. The out-of-network doctor, however, may bill you the remaining balance between what they want to charge you for services and what FirstCare has already reimbursed, as well as any copays, deductibles, and coinsurance.

I got a balance bill. What can I do about it?

• Call the doctor or provider that sent the bill and discuss your concerns. In most cases, Texas law requires providers to provide an itemized bill on request, so review the charges carefully. Some providers might accept a lower payment. You can compare the amount you were charged to the average market price using Texas Department of Insurance’s (TDI’s) Health Insurance Reimbursement Rates Consumer Information Guide or websites such as NewChoicehealth.com,  FairHealthConsumer.org, and TxPricePoint.org.

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 Health Insurance Reimbursement Rates Consumer Information Guide 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.

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:

1. Make sure you get prior authorization on any service requiring it before getting care. Find out more by talking to your physician.
2. Provide FirstCare 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. Click here for more details.

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

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

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

 
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.