Important Forms & Information

Below are resources and information FirstCare providers can access for telemedicine services, pharmacy needs, reimbursement policy forms and more.

Pharmacy Information

Prescription drug formularies, enrollment forms (specialty and mail order pharmacy), etc.

Sterilization Consent Form

Per Title 42 Code of Federal Regulations (CFR) 441, Subpart F, all sterilization procedures require a valid consent form. For timely processing, providers must complete all required fields and fax the Sterilization Consent Form to TMHP at 1-512-514-4229. TMHP should receive the Sterilization Consent Form at least five business days before the associated claim(s) are submitted.
     Sterilization Consent Form Instructions
     Sterilization Consent Form  English / Spanish

Reimbursement Policies & Forms

Documents and forms related to provider reimbursements for health care services.

Case Management/Disease Management Referrals

Telemedicine Medical Services & Telehealth Services

Any contracted FirstCare provider can provide telemedicine medical services and/or telehealth services, for certain circumstances and conditions, to a FirstCare member.
  • No pre-authorization is required by an in-network FirstCare provider. However, if an out-of-network provider is needed, pre-authorization is required. In these cases, FirstCare requires a 48-hour advance notice prior to the member receiving telemedicine services from an out-of-network provider.
  • Covered services are subject to all applicable copayments, coinsurance, and deductible amounts, not exceeding those for the same covered service provided in an in-person location such as a doctor’s office, clinic, or hospital.
  • Telemedicine provider reimbursement is related to the type of medical provider, complexity of care delivered, and the place of service. For more information, please refer to your FirstCare provider contract.
If you have any questions, contact your FirstCare Provider Relations Representative.

 

Send to a Friend

* Required field

Captcha The math problem above is intended to reduce spam.