TRS

BSWHP will provide benefits for medically necessary emergency care whether you are temporarily out of the service area or within the service area. Emergency care is defined as the sudden and unexpected onset of a condition of such a nature that a prudent layperson, possessing an average knowledge of medicine and health, believes their health could be jeopardized if they do not get immediate treatment. BSWHP will approve or deny the requested post-stabilization treatment within one hour if contacted by the provider or facility. Some examples of emergency conditions include the following:

• Unusual or excessive bleeding
• Broken bone
• Acute abdominal or chest pain
• Loss of consciousness
• Suspected heart attack
• Sudden persistent pain
• Serious burn
• Poisoning
• Convulsions
• Difficulty in breathing

In all emergency situations, you are encouraged to seek care with the nearest BSWHP-approved provider; however, if the time needed to reach a BSWHP-approved provider might endanger your health, go to the nearest emergency room. Medically necessary emergency care is covered. If you are hospitalized as a result of the emergency, you should contact the BSWHP Health Services Division within 24 to 48 hours of any admission at 888.316.7947. Coverage for continued treatment is assured when approval is obtained from the BSWHP Medical Director through the Health Services Division. Emergency care in a hospital emergency room requires a copay, which will be waived if hospital admission occurs within 24 hours.

While a medical emergency is considered a life-threatening condition, urgent care is considered less severe than an emergency, but requiring care more quickly than elective care. Urgent care includes, but is not limited to, sudden illnesses and injuries, lacerations and fever. BSWHP encourages you to access one of its Urgent Care Clinics if you find yourself needing urgent care after hours. If you do not know when to access an Urgent Care Clinic, please contact a BSWHP nurse through our Nurse Advice Line at 877.505.7947.

To make a routine appointment, contact your physician's office. To help the staff schedule your appointment quickly, please refer to the following.

• If it is your first appointment, tell the appointment clerk.
• Have your identification card ready for any required information.
• Periodic examinations (e g. annual Pap smears or history and physical) may need to be scheduled 8 to 12 weeks in advance. Other routine appointments are scheduled according to the urgency of the problem.
• If you cannot keep the appointment, notify your physician's office as quickly as possible.

You may access any of our contracted physicians. Your copay is based on whether the physician is a primary care physician or specialist. PCPs include:

• Family Practice — treats all age groups from newborns to the elderly. They provide routine medical care, referrals to specialists, some minor surgical procedures and obstetrics/gynecology services.
• Community Internal Medicine — treats patients 16 years old and older. They provide routine medical care, gynecology services and referrals to specialists.
• Pediatrics — treats children up to age 18 and provides routine care as well as referrals to specialists.
• OB/GYN — specializes in women's health and family planning.

For a list of physicians visit Find A Provider or call the number on the back of your card.

All non-emergent medical care must be provided by BSWHP network providers. You may see a network specialist without a referral. Behavioral health services and elective hospital admissions require prior authorization through BSWHP Care Coordination Department.

After-hours telephone calls or emergency requests are routed to the Baylor Scott & White Memorial Hospital operator. The Health Services Department is contacted for authorizations for inpatient admissions and emergency surgeries and procedures.

If you are enrolled in Baylor Scott & White Health Plan and are ill or injured, you can contact the Nurse Advice Line at 877.505.7947 (TTY: 711). The Nurse Advice Line is staffed 24 hours a day, every day of the year. Our nurses can give you information about how to take care of yourself at home or can help determine if an office visit, an urgent care visit or an emergency room visit is most appropriate for your symptoms. It is free, completely voluntary and confidential. However, this service is not meant to replace a doctor's care.

Baylor Scott & White Health Plan is an Open Access HMO. This means that a member can go to any network provider without a referral. Members may choose a network primary care physician (PCP) if they would like to designate one, but PCPs are not required by Baylor Scott & White Health Plan.

Refer to your Evidence of Coverage (EOC) available through the Member Portal at MyBSWHealth.com under Plan Documents. You may also call Customer Service at 844.633.5325.

Refer to your Evidence of Coverage (EOC) available through the Member Portal at My.BSWHealth.com under Plan Documents. You may also call Customer Service at 844.633.5325.

Refer to your Evidence of Coverage (EOC) available through the Member Portal at My.BSWHealth.com under Plan Documents. You may also call Customer Service at 844.633.5325.

Out-of-pocket maximums are not mutually exclusive from other out-of-pocket limits. This means that a member's total out-of-pocket maximum could contain a combination of coinsurance and/or copayments (For example, a member could pay up to $6,450 in copayments alone if there was no coinsurance paid throughout the year. If a member met the $2,000 coinsurance out-of-pocket maximum, he/she would pay $4,450 in copayments, totaling $6,450 in overall out-of-pocket expense).

You must access services through a Baylor Scott & White Health Plan network provider unless you have received prior authorization through BSWHP Health Services Division. Members do not have to file a claim for covered services provided by BSWHP network providers. The participating provider will file the claims on your behalf. Just make sure you present your member ID card at the time of service.

In the event you are treated by an Out-of-Network (OON) provider, and they will not file a claim on your behalf; you're paying the provider directly; and you have an OON benefit, please submit a claim for a Direct Member Reimbursement.

• Insured Medical Claim Form

Call Customer Service at 844.633.5325.

When your medical claims are processed by Baylor Scott & White Health Plan, you can view your Explanation of Benefits statement online through the Member Portal. The EOB outlines the disposition of your claim, including the amount paid. You must be registered for the Member Portal to view your electronic EOBs. Click the "Log In" button at the top of the page to register. You will need your member ID card to complete registration. (If you already have a member account, you can click "Log In" to view your claims information and EOBs.)

Receiving EOBs electronically ensures that benefit information is available when and where it is needed. Electronic EOBs also reduce administrative costs and demonstrate environmental awareness by reducing paper usage. Your EOBs will be delivered electronically through the portal unless you specifically request to receive paper EOBs in the mail. To request paper EOBs, log into the portal and select “Update Preferences

You can reach Customer Service at 844.633.5325 from 7 AM to 7 PM weekdays.

For services provided by non-participating providers, you will need to file a claim for reimbursement directly to BSWHP at the following address:

Baylor Scott & White Health Plan
Attn: Claims Dept.
1206 W. Campus Drive
Temple, TX 76502

In an effort to improve communication with non-English speaking members, BSWHP uses the interpretive services of AT&T (CQ Fluency). When calling a BSWHP representative, you can request to be linked to a highly-trained interpreter. Let Customer Service know your primary language and the call will be completed with the help of an AT&T interpreter. You do not have to call a special line for this service.

BSWHP also has several interpreters available through Customer Service at 844.633.5325.

BSWHP is dedicated to addressing your grievances and resolving them promptly. If there is ever a time when you are not satisfied with the performance of BSWHP or one of its providers, you should contact a Customer Service Advocate at 844.633.5325 immediately. All grievances are documented and thoroughly investigated. BSWHP encourages your input and will not discriminate against you, refuse coverage or engage in any other retaliation if you choose to file a complaint or request an appeal of a decision.

BSWHP's definition of a complaint is an oral or written form of dissatisfaction that is not able to be resolved promptly to your satisfaction. When you call Customer Service to express dissatisfaction, he/she will immediately document your issues and send you a complaint form (as required by the Texas Department of Insurance) to complete and send back to BSWHP. This form does not go into your medical record; it simply helps BSWHP address your complaint with the appropriate person or department. BSWHP responds to the oral and written complaints in the same manner and informs you of a resolution within 30 calendar days of receipt of the complaint.

BSWHP's definition of an appeal is a request for BSWHP to reverse a previous adverse decision. All appeals are presented to a panel, which is held within 30 calendar days after receipt of the request. You have the right to appear before the panel and to present written or oral information in support of your request to reverse the previous decision. The BSWHP will permit and pay for an immediate appeal to an independent review organization in the event the decision rendered was an Adverse Determination (denial of coverage based on medical necessity determination) to the complainant and the request was presented to the BSWHP within 180 days of the previous decision. For more information on your appeal rights, please contact a Customer Service Advocate at 844.633.5325.

If you are an active employee, contact your Benefits Coordinator.

BSWHP has a process whereby a group of physicians and other healthcare professionals evaluate requests for coverage of new technological procedures or treatments. The Technical Assessment Committee receives from a requesting doctor, a proposal to BSWHP that outlines a new or currently uncovered medical or behavioral procedure, devices or treatments, the perceived advantages over current therapy, criteria for utilization and supporting papers from peer-reviewed scientific journals.

The Technical Assessment Committee then meets to evaluate the physician's request for coverage. The recommendations of the Technical Assessment Committee are presented to the BSWHP Quality Improvement Committee for a final approval determination. If you have a request for coverage of a new medical or behavioral procedure, device or treatment, please contact your physician or the Health Services Division at 888.316.7947.

As a member of BSWHP, you are covered worldwide for any true emergency that occurs. Incidents such as heart attacks, deep lacerations, loss of consciousness, breathing difficulties, broken bones and other critical conditions that require immediate treatment are covered with your emergency room copay/coinsurance. If you have a medical problem that is urgent but is not an emergency, you are encouraged to contact our Nurse Advice Line at 877.505.7947. This is a 24-hour line you can access from anywhere in the world for medical advice and assistance in managing your illness.

When seeking treatment in an out-of-network emergency room, provide your member identification card. This will speed up the processing and payment of your bill by BSWHP. This will also allow the treating physician to discuss your emergency care with your network physician, if necessary.

BSWHP will cover any emergency that occurs while away at school. It will be important to plan for routine medical needs while the student is away. If your child is attending school within the State and will be located near one of our provider clinics, your child can receive care at the facility. If the student is attending school out of the BSWHP service area, it may be necessary to consider supplementary coverage for routine medical care. The student may want to use the college dispensary for his/her routine medical care. The student can also access our Nurse Advice Line at 877.505.7947 at any time for medical advice and assistance.

BSWHP is a Health Maintenance Organization (HMO) and your care has been prepaid and prearranged for within the BSWHP network. If you would like BSWHP to pay for the doctor visit, you must see a BSWHP physician. You may continue to see the physician outside the BSWHP network, but BSWHP will not pay for the visit. You may want to get copies of your medical care records from the outside doctor so that your BSWHP physician can continue care.

BSWHP network is a large, multi-specialty network and, in most cases, can meet the majority of your medical needs. If you develop a medical condition that your BSWHP network physicians cannot care for, you will need a recommendation from your BSWHP network physician and the approval of the BSWHP Medical Director before any out-of-plan services can be covered. A formal review of your case will be provided and you will receive a letter outlining clearly what BSWHP will or will not cover with the outside physician.

For more information on referrals, see the Referrals and Prior Authorizations page.

Please have someone call BSWHP within 24-48 hours of your admission so that we can begin coordinating your care as soon as possible. The instructions for reporting an out-of-plan admission are printed on the back of your member identification card. Simply use the toll-free line.

If you are hospitalized while traveling with others, we suggest that you always have someone else within your group know what to do in case you are unable to speak for yourself.

Refer to the Formulary Management document for information about pharmaceutical management procedures.

If you have any questions about Baylor Scott & White Health Plan, please call Customer Service at 844.633.5325.

If you would like to know the professional qualifications of a BSWHP network physician, visit our Find A Provider page or call Customer Service at 844.633.5325. You can inquire about your physician's medical school, residency, board certification status and any other information you may need to choose a practitioner in the network

Baylor Scott & White Health Plan is an Open Access HMO. A member can go to any network provider without a referral.

Members may choose a network primary care physician (PCP) if they would like to designate one, but PCPs longer required by the Baylor Scott & White Health Plan.

If you would like to select a PCP, please refer to our online directory. Each person listed on your plan may select a PCP from the following physicians:

• Family Practice treats all age groups from newborns to the elderly. They provide routine medical care, referrals to specialists, some minor surgical procedures and obstetrics/gynecology services.
• Internal Medicine physicians treat patients 16 years and older. They provide routine medical care, gynecology services and referrals to specialists.
• Pediatricians treat treats children up to age 18 and provide routine care as well as referrals to specialists.
• OB/GYNs specialize in women's health and family planning.

When selecting a PCP, consider which clinic would be most convenient to meet your own needs. Each person listed on your plan can select his or her own doctor.

If you would like specific information about any of the PCPs, click on Find A Provider or contact Customer Service. Once you select a PCP, you can make an appointment with that physician. If your PCP is unavailable, you can see any other physicians of the same specialty that work with the clinic.

You can change your PCP anytime.

No covered person is required to designate a PCP. If they wish to do so, each person listed on your plan can select his or her own doctor.

You can go straight to the Member Portal at My.BSWHealth.com. You can also navigate to the portal by clicking the "Log In" button in the upper right corner of each page on this site. You will need your member ID, Social Security Number and date of birth to register initially to the secure site.

On the Member Portal, you can:

• View and print ID cards
• View benefits and coverage
• See claims and Explanations of Benefits (EOBs)
• View deductibles and out-of-pocket accumulators
• Take a wellness assessment
• Send an email to customer service advocates through secure messaging feature

The Member Portal also features a cost estimator and a provider search based on your specific health plan.

For our Individual and Family Plan members, the Member Portal will help you learn how to:

• Make payments online
• Set up recurring payments
• Access forms
• Check to see if payment was received
• Make demographic changes (address, phone, etc.)

Your account will automatically be unlocked 30 minutes after the last failed login attempt. After 30 minutes, click "Forgot Password" and reset your password.

Accounts are automatically locked after five failed attempts to prevent other programs from cracking members' passwords.

First, verify your username is correct. All usernames are an email address specified by the member upon registering for the Member Portal. If you have multiple email addresses, try a different one.

You should contact Customer Service at 844.633.5325. They can help you with many issues. If they can't help, they will take your contact information and forward it to a subject matter expert. In most cases you will get a resolution in a couple of hours via email or a return phone call. Also, check your Spam folder.

If you didn't get an email, try again to reset your password and double-check the email address that you type in is correct. If you mistype even one letter, you will not receive the password reset email.

It could be that you typed in your email address incorrectly when you first registered. If you suspect this is the problem, contact Customer Service at 844.633.5325 and they can verify your email address or submit a correction request, which should be completed in a few hours.

A Social Security Number is not required to apply for coverage with Baylor Scott & White Health Plan. So if you didn't provide an SSN during your application process, we do not have your SSN on file. You will therefore not be able to use it to register. Instead, if you have it, use your member ID number and date of birth. If you do not know your member ID number, please contact Customer Service at 844.633.5325.

First, verify that you're typing in the correct member ID number. If you are, contact Customer Service at 844.633.5325. It's possible that your date of birth is incorrect in our system. If you are a new member, it's possible your application has not yet been processed. As soon as your application is processed, you should be able to register for the Member Portal online.

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