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FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSAUTHORIZATION INFORMATIONCONTACT USBECOMING A PROVIDERPROVIDER NEWSFIND A PROVIDER COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - INDIVIDUAL & FAMILY HEALTH PLANS MARKETPLACE You can obtain forms for the submission of written proof of payment by contacting our Customer Service Department at 1.855.572.7238 for more information or click here for a copy of the claim form. Once you fill out the claim form, mail it to: FirstCare Health Plans. P.O. Box211342.
FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the-SCOTT AND WHITE
Scott and White. Welcome to myScott&White 24/7 Self-Service. New to Scott and White Health Plan? Create an account today! FC 2021 FIRSTCARE ELITE GOLD HMO 001 GHIF1M01 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Elite Gold HMO 001 – 26539TX0140001-01 Coverage for: Member/Family | Plan Type: HMO STAR AND CHIP PROVIDER MANUAL April 2020 Provider Manual. STAR and CHIP. Lubbock Service Area / Medicaid Rural Service Area (MRSA West) FC-P001 04/20. Provider Relations . 1-800-264-4111 ADJUSTMENT AND REDETERMINATION REQUEST … FC-ADJ_RDT_PRC-0220 ADJUSTMENT AND REDETERMINATION REQUEST COMMUNICATION PROCESS-MEDICAID Below you will find the steps necessary to submit a claim for reprocessing (adjustments ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSAUTHORIZATION INFORMATIONCONTACT USBECOMING A PROVIDERPROVIDER NEWSFIND A PROVIDER COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - INDIVIDUAL & FAMILY HEALTH PLANS MARKETPLACE You can obtain forms for the submission of written proof of payment by contacting our Customer Service Department at 1.855.572.7238 for more information or click here for a copy of the claim form. Once you fill out the claim form, mail it to: FirstCare Health Plans. P.O. Box211342.
FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the-SCOTT AND WHITE
Scott and White. Welcome to myScott&White 24/7 Self-Service. New to Scott and White Health Plan? Create an account today! FC 2021 FIRSTCARE ELITE GOLD HMO 001 GHIF1M01 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Elite Gold HMO 001 – 26539TX0140001-01 Coverage for: Member/Family | Plan Type: HMO STAR AND CHIP PROVIDER MANUAL April 2020 Provider Manual. STAR and CHIP. Lubbock Service Area / Medicaid Rural Service Area (MRSA West) FC-P001 04/20. Provider Relations . 1-800-264-4111 ADJUSTMENT AND REDETERMINATION REQUEST … FC-ADJ_RDT_PRC-0220 ADJUSTMENT AND REDETERMINATION REQUEST COMMUNICATION PROCESS-MEDICAID Below you will find the steps necessary to submit a claim for reprocessing (adjustments ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members. FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANS Prior Authorization Process. Certain services require authorization in order to be covered by FirstCare Health Plans. Authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment—including prescribed drug intervention—relative to approved evidence-based medical criteria. FIRSTCARE - CONTACT FIRSTCARE FOR INFORMATION ON TEXAS 1-800-431-7798. CHIP. 1-877-639-2447. FirstCare Advantage Dual SNP (HMO SNP)¹. 1-866-229-4969¹. TTY/TDD. 711. ¹FirstCare Advantage Dual SNP (HMO SNP) Hours of Operation: October 1 - March 31, 8 a.m. - 8 p.m. CT, daily; April 1 - September 30, 8 a.m. - 8 p.m. CT, Monday - Friday. You can request information in larger print, audio (CD FIRSTCARE - FIRSTCARE HEALTH PLANS NEWS & INDUSTRY INFORMATION Thursday, January 3, 2019. As of January 1, 2019, Scott and White Health Plan, part of Baylor Scott & White Health, has acquired FirstCare Health Plans. The combined plans will cover almost 400,000 members across North, West, and Central Texas. Our organizations are now beginning the important work of transitioning into one, first-rate FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANS FirstCare Health Plans provides access to high-quality, affordable health care for our customers, through strong partnerships in the communities we serve. At FirstCare, we put you first. FIRSTCARE - ADD DENTAL & VISION BENEFITS TO YOUR FIRSTCARE FirstCare Dental and Vision Benefits — Powered by Ameritas ®. We've partnered with Ameritas® to provide your employees with opportunity to enhance their health care coverage through the these specialty products. With options including dental-only coverage, vision-only coverage, and a combined dental-vision plan (Fusion: The UltimateChoice
FIRSTCARE HMO PLAN QUICK REFERENCE GUIDE 1. Quick Reference Guide. FirstCare HMO Plan . FirstCare.com. HMO: What You Should Know. At FirstCare Health Plans, we encourage our HMO(Health Maintenance
MEDICAL COVERAGE POLICY ICD-10 CODES MEDICAL COVERAGE POLICY SERVICE: Oncology Analytics® In Scope ICD-10 Codes Policy Number: 275 Effective Date: 10/01/2020 Last Review:09/24/2020
SAMPLE ID CARD
Remember to carry your FirstCare member ID card with you at all times. You will need to show it at each office visit as well as the pharmacy.FirstCare member ID
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSAUTHORIZATION INFORMATIONCONTACT USBECOMING A PROVIDERPROVIDER NEWSFIND A PROVIDER COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website. FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the-SCOTT AND WHITE
Scott and White. Welcome to myScott&White 24/7 Self-Service. New to Scott and White Health Plan? Create an account today! FC 2021 FIRSTCARE ELITE GOLD HMO 001 GHIF1M01 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Elite Gold HMO 001 – 26539TX0140001-01 Coverage for: Member/Family | Plan Type: HMOSAMPLE ID CARD
Remember to carry your FirstCare member ID card with you at all times. You will need to show it at each office visit as well as the pharmacy.FirstCare member ID
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSAUTHORIZATION INFORMATIONCONTACT USBECOMING A PROVIDERPROVIDER NEWSFIND A PROVIDER COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website. FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the-SCOTT AND WHITE
Scott and White. Welcome to myScott&White 24/7 Self-Service. New to Scott and White Health Plan? Create an account today! FC 2021 FIRSTCARE ELITE GOLD HMO 001 GHIF1M01 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Elite Gold HMO 001 – 26539TX0140001-01 Coverage for: Member/Family | Plan Type: HMOSAMPLE ID CARD
Remember to carry your FirstCare member ID card with you at all times. You will need to show it at each office visit as well as the pharmacy.FirstCare member ID
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not FIRSTCARE - MYFIRSTCARE SELF-SERVICE FirstCare members can talk to a nurse 24/7 by calling 1-877-505-7947 (TTY 711) to get answers 24 hours a day, 7 days a week! STAR and CHIP Members call 1-855-828-1013 (TTY 711) . 24/7 Self-Service Portal.Member Resources.
FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members. FIRSTCARE - CONTACT FIRSTCARE FOR INFORMATION ON TEXAS 1-800-431-7798. CHIP. 1-877-639-2447. FirstCare Advantage Dual SNP (HMO SNP)¹. 1-866-229-4969¹. TTY/TDD. 711. ¹FirstCare Advantage Dual SNP (HMO SNP) Hours of Operation: October 1 - March 31, 8 a.m. - 8 p.m. CT, daily; April 1 - September 30, 8 a.m. - 8 p.m. CT, Monday - Friday. You can request information in larger print, audio (CD MEDICAL COVERAGE POLICY SERVICE: COVID-19 TELEHEALTH AND MEDICAL COVERAGE POLICY SERVICE: COVID-19 Telehealth and Telemedicine Policy Number: 262 Effective Date: 05/21/2020 Last Review: 05/21/2020 FIRSTCARE - INDIVIDUAL & FAMILY HEALTH INSURANCE IN TEXAS To qualify for FirstCare Advantage Dual SNP (HMO SNP) you would need to have Medicare and Medicaid which would allow you to enroll. Contact us for information at 1-866-229-4969. Later in the year, from October 15 through December 7, anyone with Medicare can switch their way of getting Medicare to another way for the following year. If you join FIRSTCARE STAR MEDICAID PRIOR AUTHORIZATION LIST Prior Authorization List General Information FirstCare STAR Medicaid Prior Authorization List (Effective January 1, 2020) 3 1.We collect clinical information before elective inpatient admissions and/or selected ambulatory procedures and services take place. FIRSTCARE HMO PLAN QUICK REFERENCE GUIDE 1. Quick Reference Guide. FirstCare HMO Plan . FirstCare.com. HMO: What You Should Know. At FirstCare Health Plans, we encourage our HMO(Health Maintenance
MEDICAL COVERAGE POLICY ICD-10 CODES MEDICAL COVERAGE POLICY SERVICE: Oncology Analytics® In Scope ICD-10 Codes Policy Number: 275 Effective Date: 10/01/2020 Last Review:09/24/2020
CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not ADJUSTMENT AND REDETERMINATION REQUEST … FC-ADJ_RDT_PRC-0220 ADJUSTMENT AND REDETERMINATION REQUEST COMMUNICATION PROCESS-MEDICAID Below you will find the steps necessary to submit a claim for reprocessing (adjustments FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSAUTHORIZATION INFORMATIONCONTACT USBECOMING A PROVIDERPROVIDER NEWSFIND A PROVIDER COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website. FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the-SCOTT AND WHITE
Scott and White. Welcome to myScott&White 24/7 Self-Service. New to Scott and White Health Plan? Create an account today! FC 2021 FIRSTCARE ELITE GOLD HMO 001 GHIF1M01 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Elite Gold HMO 001 – 26539TX0140001-01 Coverage for: Member/Family | Plan Type: HMOSAMPLE ID CARD
Remember to carry your FirstCare member ID card with you at all times. You will need to show it at each office visit as well as the pharmacy.FirstCare member ID
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSAUTHORIZATION INFORMATIONCONTACT USBECOMING A PROVIDERPROVIDER NEWSFIND A PROVIDER COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website. FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the-SCOTT AND WHITE
Scott and White. Welcome to myScott&White 24/7 Self-Service. New to Scott and White Health Plan? Create an account today! FC 2021 FIRSTCARE ELITE GOLD HMO 001 GHIF1M01 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Elite Gold HMO 001 – 26539TX0140001-01 Coverage for: Member/Family | Plan Type: HMOSAMPLE ID CARD
Remember to carry your FirstCare member ID card with you at all times. You will need to show it at each office visit as well as the pharmacy.FirstCare member ID
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not FIRSTCARE - MYFIRSTCARE SELF-SERVICE FirstCare members can talk to a nurse 24/7 by calling 1-877-505-7947 (TTY 711) to get answers 24 hours a day, 7 days a week! STAR and CHIP Members call 1-855-828-1013 (TTY 711) . 24/7 Self-Service Portal.Member Resources.
FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members. FIRSTCARE - CONTACT FIRSTCARE FOR INFORMATION ON TEXAS 1-800-431-7798. CHIP. 1-877-639-2447. FirstCare Advantage Dual SNP (HMO SNP)¹. 1-866-229-4969¹. TTY/TDD. 711. ¹FirstCare Advantage Dual SNP (HMO SNP) Hours of Operation: October 1 - March 31, 8 a.m. - 8 p.m. CT, daily; April 1 - September 30, 8 a.m. - 8 p.m. CT, Monday - Friday. You can request information in larger print, audio (CD MEDICAL COVERAGE POLICY SERVICE: COVID-19 TELEHEALTH AND MEDICAL COVERAGE POLICY SERVICE: COVID-19 Telehealth and Telemedicine Policy Number: 262 Effective Date: 05/21/2020 Last Review: 05/21/2020 FIRSTCARE - INDIVIDUAL & FAMILY HEALTH INSURANCE IN TEXAS To qualify for FirstCare Advantage Dual SNP (HMO SNP) you would need to have Medicare and Medicaid which would allow you to enroll. Contact us for information at 1-866-229-4969. Later in the year, from October 15 through December 7, anyone with Medicare can switch their way of getting Medicare to another way for the following year. If you join FIRSTCARE STAR MEDICAID PRIOR AUTHORIZATION LIST Prior Authorization List General Information FirstCare STAR Medicaid Prior Authorization List (Effective January 1, 2020) 3 1.We collect clinical information before elective inpatient admissions and/or selected ambulatory procedures and services take place. FIRSTCARE HMO PLAN QUICK REFERENCE GUIDE 1. Quick Reference Guide. FirstCare HMO Plan . FirstCare.com. HMO: What You Should Know. At FirstCare Health Plans, we encourage our HMO(Health Maintenance
MEDICAL COVERAGE POLICY ICD-10 CODES MEDICAL COVERAGE POLICY SERVICE: Oncology Analytics® In Scope ICD-10 Codes Policy Number: 275 Effective Date: 10/01/2020 Last Review:09/24/2020
CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not ADJUSTMENT AND REDETERMINATION REQUEST … FC-ADJ_RDT_PRC-0220 ADJUSTMENT AND REDETERMINATION REQUEST COMMUNICATION PROCESS-MEDICAID Below you will find the steps necessary to submit a claim for reprocessing (adjustmentsFIRSTCARE
FirstCare. Welcome to myFirstCare 24/7 Self-Service. New to myFirstCare? Create an account today! FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANS COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the- FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE One $25 gift card per year for new or existing STAR members age 20 and under who get a timely Texas Health Steps checkup. To request gift card, call 1‑800‑431‑7798 or complete the form. online / printable. One $20 gift card for STAR members who have a follow-up doctor visit within 7 days of discharge from a behavioral healthhospital stay.
STAR AND CHIP PROVIDER MANUAL April 2020 Provider Manual. STAR and CHIP. Lubbock Service Area / Medicaid Rural Service Area (MRSA West) FC-P001 04/20. Provider Relations . 1-800-264-4111 FC 2021 FIRSTCARE PRIME SILVER HMO 003 SHIF1M03 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Prime Silver HMO 003 – 26539TX0140003-01 Coverage for: Member/Family | Plan Type: HMO ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but notFIRSTCARE
FirstCare. Welcome to myFirstCare 24/7 Self-Service. New to myFirstCare? Create an account today! FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANSPROVIDERSVIRTUAL CARE POWERED BY MDLIVEMEMBER RESOURCESCAREERSTOOLS & RESOURCES The COVID-19 Vaccine is available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates. COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospitalstays.
FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANS COVID-19 Testing/Treatment: Effective March 6, 2020, and until further notice, FirstCare Health Plans is waiving member cost-sharing for care related to COVID-19, which includes testing, telehealth services, outpatient office visits and inpatient hospital stays. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE Welcome to FirstCare STAR. Our goal is to give you quality care and a great network of doctors, specialists and hospitals. STAR members receive Medicaid health care benefits, including Texas Health Steps (THSteps) medical and dental checkups. For more details, call THSteps toll-free at 1-877-847-8377 or visit the THSteps website.2ND QUARTER 2021
P a g e | 4 Revised 10/21/2020 • A drug may be withdrawn from the market by the FDA. • A drug becomes available without a prescription (becomes available over-the- FIRSTCARE - STAR MEDICAID HEALTH PLANS IN TEXAS WITH FIRSTCARE One $25 gift card per year for new or existing STAR members age 20 and under who get a timely Texas Health Steps checkup. To request gift card, call 1‑800‑431‑7798 or complete the form. online / printable. One $20 gift card for STAR members who have a follow-up doctor visit within 7 days of discharge from a behavioral healthhospital stay.
STAR AND CHIP PROVIDER MANUAL April 2020 Provider Manual. STAR and CHIP. Lubbock Service Area / Medicaid Rural Service Area (MRSA West) FC-P001 04/20. Provider Relations . 1-800-264-4111 FC 2021 FIRSTCARE PRIME SILVER HMO 003 SHIF1M03 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Prime Silver HMO 003 – 26539TX0140003-01 Coverage for: Member/Family | Plan Type: HMO ELECTRONIC FUNDS TRANSFER AUTHORIZATION AND W-9 electronic funds transfer authorization agreement vendor information new request update vendor name (company name) vendor number (to be completed by scott & white) address city state zip CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not FIRSTCARE - INDIVIDUAL & FAMILY HEALTH PLANS MARKETPLACE You can obtain forms for the submission of written proof of payment by contacting our Customer Service Department at 1.855.572.7238 for more information or click here for a copy of the claim form. Once you fill out the claim form, mail it to: FirstCare Health Plans. P.O. Box211342.
FIRSTCARE - SCOTT AND WHITE HEALTH PLAN TO ACQUIRE FIRSTCARE Scott and White Health Plan and FirstCare Health Plans, part of Baylor Scott & White Health, are two years into operating as one team. Together, we are incorporating the best of both companies and continue to introduce new insurance plans, technology and services to meet the needs of our combined 360,000+ members. FIRSTCARE - STAR MEDICAID AND CHIP HEALTH PLANS IN TEXAS Our Customer Advocates will be happy to help you by phone by calling 1-800-431-7798 (STAR) or 1‑877‑639‑2447 (CHIP), Monday to Friday, 8am to 5pm. You also have 24/7 access to the Member Portal. The portal gives online access to: Visit my.FirstCare.com to set it up today. Medicaid members who have renewals due during the pandemic will FIRSTCARE - HEALTH PLANS BY TEXANS FOR TEXANS Prior Authorization Process. Certain services require authorization in order to be covered by FirstCare Health Plans. Authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment—including prescribed drug intervention—relative to approved evidence-based medical criteria. FIRSTCARE - INDIVIDUAL & FAMILY HEALTH INSURANCE IN TEXAS To qualify for FirstCare Advantage Dual SNP (HMO SNP) you would need to have Medicare and Medicaid which would allow you to enroll. Contact us for information at 1-866-229-4969. Later in the year, from October 15 through December 7, anyone with Medicare can switch their way of getting Medicare to another way for the following year. If you join FIRSTCARE HMO PLAN QUICK REFERENCE GUIDE 1. Quick Reference Guide. FirstCare HMO Plan . FirstCare.com. HMO: What You Should Know. At FirstCare Health Plans, we encourage our HMO(Health Maintenance
MEDICAL COVERAGE POLICY ICD-10 CODES MEDICAL COVERAGE POLICY SERVICE: Oncology Analytics® In Scope ICD-10 Codes Policy Number: 275 Effective Date: 10/01/2020 Last Review:09/24/2020
FC 2021 FIRSTCARE PRIME SILVER HMO 012 SHIF1D35 SBC 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 FirstCare Health Plans: FirstCare Prime Silver HMO 012 – 26539TX0140012-00 Coverage for: Member/Family | Plan Type: HMOSAMPLE ID CARD
Remember to carry your FirstCare member ID card with you at all times. You will need to show it at each office visit as well as the pharmacy.FirstCare member ID
CARE MANAGEMENT SERVICES CLINICAL GUIDELINE Minimally invasive pain management may be considered medically necessary for 1 or more of the following: Sacroiliac joint injections are needed for 1 or more of the following : o The member is in the Diagnostic Phase and ALL of the following: Sacroiliac joint pain resulting from disease, injury or surgery Failure to improve after three months of conservative treatment including, but not* Find a Provider
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more information and benefit updates. COVID-19 TESTING/TREATMENT: Effective March 6, 2020, and until further notice, FirstCare Health Plans is WAIVING MEMBER COST-SHARING FOR CARE RELATED TO COVID-19, WHICH INCLUDES TESTING, TELEHEALTH SERVICES, OUTPATIENT OFFICE VISITS AND INPATIENT HOSPITAL STAYS. This applies to fully insured Commercial and Medicare Advantage Dual SNP members. Members of self-funded employer groups should contact their Human Resources Department for information on covered benefits. Find your 1095-B in the Member Portal If you need a 1095-B tax form verifying health insurance coverage for 2020, log in to MyBSWHealth.com . In the left-hand menu, select “Insurance & Billing,” then “FirstCare Health Plans” and “Tax Forms." Have a question? Message us through the member portal. The new year has brought new members to our health plan, and we're receiving more phone calls than usual. We want you to know that we value your phone call and are actively working to reduce wait times. Did you know you can send your inquiry through the secure messaging feature of the MyBSWHealth member portal and we’ll get back to you, usually within 1-2 business days? Click here for other helpful information andresources
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HEALTH PLANS THAT WORK FOR TEXANS™ Here at FirstCare Health Plans, we’ve been specializing in Texas health insurance plans for over 35 years. In fact, we were born and bred right here in the Lone Star State. We’re owned by Texas-based Scott and White Health Plan—part of Baylor Scott & White Health—and today, we serve more than 350,000 friends and neighbors in 171 counties throughout west and central Texas, including areas underserved by other health plans. We’re here to make sure that our members and communities have access to high-quality health insurance at affordable rates. Quality health insurance in Texas doesn’t have to be complicated or overpriced. And at FirstCare, we put you first! Learn more today about our individual/family plans, Medicare, STAR and CHIP coverage, and group health plan options. ------------------------- Scrubbing In® takes Baylor Scott & White Health’s more than 115 years of experience as a health care provider beyond the walls of our hospitals and clinics straight to you. Scrubbing In® is a place where hands-on health care discussions happen every day with the people whose own hands are on the front lines of patient care, the doctors, nurses and medical staff who are saving lives and advancing medicine.LATEST HEADLINES:
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