Important Plan Information
We know that health insurance can be confusing, so we've gathered information on the topics listed below to help explain FirstCare's payment policies and other important aspects of your plan's coverage.
Click on any of the topics below for more details.
Out-of-Network Liability & Balance Billing
This is when out-of-network providers bill patients for the balance between the amount charged to their patients and what FirstCare has already reimbursed
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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?
How can I protect myself from a bill?
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Retroactive Denials
A previously paid claim can be reversed by FirstCare—this is a retroactive denial
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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:
- Make sure you get prior authorization on any service requiring it before getting care. Find out more by talking to your physician.
- Provide FirstCare with updated information on any other health insurance you may have so we can coordinate payment with the other insurance company.
- 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.
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Medical Necessity & Prior Authorizations
Medically necessary care is health care resulting from an illness or injury, and, for some services, requires prior authorization by FirstCare.
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.
NOTE: This listing is subject to change and members will receive prior notification of any changes to this list.
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Continuity of Care/Transition of Care Request Form
This document provides information about a Continuity of Care/Transition of Care request.
If you would like to see if you are eligible to participate in transition of care, please:
- Call Customer Service number on the back of your ID card, and they will assist you with understanding how you should complete your form.
- Or, fax this completed request form to Health Services Department at 1-800-248-1852
- Or, mail to FirstCare Health Plans, 12940 N. Hwy 183 Austin, TX 78750 ATTN: Health Services Department
Click here for
Continuity of Care/Transition of Care Request Form.
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Prescription Drug Exception Timeframes
You or your physician can ask FirstCare to make an exception to our coverage rules on your prescription drug coverage
.
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.
NOTE: This listing is subject to change and members will receive prior notification of any changes to this list.
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Concurrent Review
This review helps us ensure you are receiving the right care, in the right setting, for your condition
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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.
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Questions? Contact Us!
If you have any questions about your plan, your benefits, or FirstCare—our Customer Service team is standing by, ready to assist you.
- Please call us at 1-800-884-4901 (HMO) or 1-800-240-3270 (PPO), Monday through Friday, 7 a.m. - 7 p.m. CT
For details on information in other languages, click
here.