Scott & White Health Plan

Referrals and Prior Authorizations Under Your Medical Plan

To receive the maximum benefit from your Scott & White Health Plan (SWHP) medical plan, you will need to use SWHP-approved doctors, hospitals, pharmacies, and other providers of medical services that are covered by your plan. In the event of an emergency, it is important that you go to the nearest hospital that can provide the best care for your needs. In this case, you may use doctors or hospitals outside the SWHP network.

When you need non-emergency medical services you always have the choice of using out-of-network providers. However, you will not receive the benefits of your SWHP medical plan, and you will be responsible for the full cost of any medical services you receive.   

Most services you need are available through the Scott & White Healthcare system. Your Primary Care Physician (PCP) may coordinate a referral for these services. Some services may also require your PCP to ask SWHP for prior authorization. If you want to be sure SWHP will pay for this service, you will need prior authorization before these procedures are performed. When authorization is given, SWHP will provide coverage for these services based on the terms of your specific plan.

While this list is subject to change, some examples of services, procedures, or tests that may require prior authorization by SWHP include, but may not be limited to the following:

Notification requested:

• Acute (contracted ) hospital admissions (medical, surgical, behavioral health)
• Admissions to inpatient or outpatient (contracted) hospice programs

Prior Authorization required:

• Admissions to LTAC, Rehabilitation, and SNF facilities
• Admissions to behavioral health/substance abuse residential, partial hospitalization, and day programs (not office visits to contracted providers)
• Neuropsychological and psychological testing
• Applied behavioral analysis therapy
• Outpatient electroconvulsive therapy (ECT)
• All services to be provided by non-contracted providers
• Solid organ and stem cell transplants
• Weight loss (bariatric) surgeries (if a covered benefit, not covered by many plans)
• Procedures which may be considered cosmetic and thus not covered (e.g. face lift, brow lift, blepharoplasty, liposuction, abdominoplasty, breast reconstruction (not associated with medically indicated mastectomy), surgery for gynecomastia, rhinoplasty, genioplasty, treatment of varicose veins, etc.)
• Orthognathic surgery
• Treatments for sleep apnea
• Home health services, including all requests for hourly or private duty nursing
• Durable medical equipment (DME)
• Orthotics and prosthetics
• Spinal fusion and vertebroplasty
• Ventricular assist devices (VAD)
• Genetic testing

This list is subject to change.

If you have  questions about referrals or prior authorizations, please contact our Customer Advocacy Team at (800) 321-7947 or submit your request for assistance online.

Updated 1/2012