Referrals and Prior Authorizations Under the Medical Plan

Except for Emergency Care Services, Plan-approved physicians and providers must provide all services under your Health Care Agreement. Most services are available through the S&W system of care and only require coordination of the referral through your Primary Care Physician (PCP) to other SWHP-approved physicians (including specialists) and/or providers and no authorization through the Health Services Division (HSD) of Scott and White Health Plan (SWHP) is required. An occasional service requires notification from your PCP to the Plan that they will handle for you. SWHP provides coverage for these services coordinated through your PCP under the terms of your specific Health Care Agreement.

When a service requires prior authorization through the HSD, it is usually due to a service having a limited benefit, being an out-of-Plan referral for services and/or a service that may potentially be a non-covered benefit under the “Exclusions and Limitations” section of your Health Care Agreement. These services are required to be submitted to the Plan in advance of the service by your PCP and/or Plan-approved specialist or provider in order to receive an individual case review and coverage determination by the Plan Medical Directors. If you seek these types of services without the required prior approval coverage determination, you may be at risk for all charges associated with the service. (Examples include, but are not limited to: Plastic Surgery; Dental/Oral Surgery; Transplants; non-urgent/emergent transports; all out-of-Plan services; bariatric surgery; etc.)

If you and/or your physician have a question as to whether a service requires prior authorization through the Health Services Division, you may contact your SWHP Customer Service Coordinator (CSC) at the number in your local area and/or at the main Temple site. If a referral has been submitted to the HSD through the prior authorization process, you may check that it has been received by also calling the CSCs and/or by calling the HSD at 1-888-316-7947. Determinations are made as quickly as possible within Texas Department of Insurance (TDI) time regulations, but require your physicians and/or providers to submit all information needed to make the determination. Once a decision has been rendered, the HSD will attempt to reach you and your physician(s) and/or providers three times to deliver a verbal authorization determination. If the service is denied for any reason, you will be provided your complaint/appeal rights and information on how to access the process. You will also receive in the mail, a letter outlining the coverage determination and the complaint/appeal process, if applicable.

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