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 Marketplace plan coverage.
 

Click on any of the topics below for more details.  

Out-of-Network Liability & Balance Billing

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 . 

Member Claim Submissions

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

Filing an Appeal

Did you disagree with our resolution on your claim?

Grace Periods & Pending Claims

Do you need to file a claim direclty to FirstCare?

Retroactive Denials

A previously paid claim can be reversed by FirstCare—this is a retroactive denial.

Member Recoupment of Overpayments

Did you overpay on your monthly premium invoice?  If so, let us know.

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.

Concurrent Review

This review helps us ensure you are receiving the right care, in the right setting, for your condition.

Prescription Drug Exceptions

You or your physician can ask FirstCare to make an exception to our coverage rules on your prescription drug coverage.

Explanation of Benefits (EOBs)

After receiving covered health services, an EOB will show you what was billed and what FirstCare paid.

Coordination of Benefits (COB)

How to understand who pays your claim first.

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.
For details on information in other languages, click here.

FirstCare is here for you.

We can help you find a plan that fits your needs. Contact us today!

Resources

FirstCare's Direct Enrollment Portal Service Area Map (2017) Service Area Map (2018) Find a Provider Get a Quote Pay Your Premium Rate Review Justification

Non-Discrimination Notice

FirstCare does not discriminate or exclude people based on race, color, national origin, age, disability, or sex. Read more here.

Ask the Pharmacist

Have a question about a specific drug, or a drug benefit in your plan? Email our Pharmacist for the answers you need!

Talk to a Nurse—Nurse24™

Need care advice? Should you see a doctor? Get the info you need today! FirstCare members can talk to a nurse 24/7 by calling 1.855.828.1013 to get answers 24 hours a day, 7 days a week! TTY users can call 7-1-1 or  1.800.955.8771. Voice communication is available at 1.800.955.8770.

Utilization Management

Ever wonder how we decide what services to authorize for our members? Our utilization management (UM) decisions are based on medical evidence and consensus of health care professionals. For more details, click here.

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