Indemnity Plans

The benefit of choosing an indemnity plan as your type of health insurance plan, otherwise known as a fee-for-service plan, is that it doesn't bog you down into a single network of physicians. Indemnity plan holders are given the freedom to choose/visit the doctor of their choice. In the case of indemnity plans, the remaining bill is then submitted to the insurance provider who pays the covered expenses. (Typically this consists of approx. 80% of the bill, leaving indemnity plan holders to pay the other 20%) This type of health insurance plan generally has what is called an "out-of-pocket" maximum. After this kicks in, your health plan provider pays for all covered benefits.

What you should know prior to purchase?



Although the most expensive type of health insurance policy, indemnity, or Fee-for-service insurance gives you the most flexibility and freedom to go to the doctor / medical facility / health care specialist of your choice. After receiving treatment, you must submit a claim to your insurance company (doctor or facility generally handles submissions) in order to receive reimbursement. Indemnity plans are customized so as to fit the needs of each unique policyholder, and as such, you will only be reimbursed for healthcare expenditures specified by your policy.

Types of HMO

Health Maintenance Organizations (HMOs)

Health maintenance organizations are prepaid health plans. As an HMO member, insured pay a monthly premium. In exchange, the HMO provides comprehensive care for the insured & his family, including doctors' visits, hospital stays, emergency care, surgery, laboratory (lab) tests, x-rays, and therapy.

The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, patient choices of doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when medically necessary.

There may be a small co-payment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Individual total medical costs will likely be lower and more predictable in an HMO than with fee-for-service insurance.

Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure patient get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered varies in HMOs, so it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis.
Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO individual may have to wait longer for an appointment than he would with a fee-for-service plan.

In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in individual’s community as part of a prepaid group practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. Individual select a doctor from a list of participating physicians that make up the IPA network. If an individual is thinking of switching into an IPA-type of HMO, he needs to check whether doctor participates in the plan.


In almost all HMOs, individuals are either assigned or choose one doctor to serve as patient’s primary care doctor. This doctor monitors health and provides most of patient’s medical care, referring to specialists and other health care professionals as needed. Patient usually cannot see a specialist without a referral from primary care doctor who is expected to manage the care received by the patient. This is one way that HMOs can limit patient’s choice.

Types of HMOs

HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together.


In the staff model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients.

In the group model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.[4]

Physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.

In the network model, an HMO will contract with any combination of groups, IPAs, and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.



HMO Plans


HMOs are the least expensive, but also the least flexible of all the health insurance plans. They are geared more toward members of a group seeking health insurance.

HMO advantages: 

• They offer their customers low co-payments, minimal paperwork, and coverage for many preventive-care and health-improvement programs.

HMO disadvantages:

• Individual must choose a primary care physician, also known as a PCP.

• HMOs require that individual see only network doctors or they won't pay.

• Individual must get a referral from your PCP to see a specialist.

What Is a HMO Insurance Policy?

What Is a HMO Insurance Policy?

HMOs, or health maintenance organizations, are one of many types of health insurances available to help cover health-related expenses.


Identification
A health maintenance organization pays for health care provided by members of a network of doctors and hospitals established by the company.
 
Types

Group HMOs are offered through employers or associations for their employees or members and their families. The employer pays for part of the coverage. Individual HMOs are purchased directly from the provider by one person or a family.

Features

HMOs typically require patients to choose a Primary Care Physician and then visit that doctor for care or to receive a referral for a specialist.

Expenses

In exchange for the coverage provided by an HMO, it is necessary to pay a bi-weekly, monthly or annual premium, with group plans typically having lower premiums that individual plans. HMO insurance usually requires the insured to pay co-pays or fees when visiting a doctor or emergency room.

Benefits

HMO insurance policies usually require members to pay fewer health care expenses on their own than other types of health insurance according to the Insurance Information Institute.

Considerations

In some cases, you may be denied coverage by an HMO due to a pre-existing condition or an illness or condition that you have when you apply for coverage. Group policies sometimes feature open enrollment, which guarantees employees coverage despite their general health.

What is the difference between HMO and PPO

Difference between HMO and PPO

A health maintenance organization (HMO) and a preferred provider organization (PPO) have several differences. However, many of them offer quite similar services. Often the PPO will cost a little more because it provides greater flexibility in choosing doctors and seeing specialists than does the HMO.


With a PPO, one can see any doctor one wishes, or visit any hospital one chooses, usually within a preferred network of providers. Depending upon the terms of coverage, a doctor or hospital outside the preferred provider list will cost more and the PPO will pay a range of 70-80% of expenses. Conversely, an HMO requires one see only doctors or hospitals on their list of providers.

few exceptions exist. A large HMO like Kaiser Permanente may allow one to use hospitals or specialists that perform a service their contracted doctors and facilities don’t provide. Unless the health situation is an emergency, obtaining services like these usually involve approval processes and may require a great deal of paperwork and red tape.


The HMO generally also requires that one choose a primary care physician, who will direct care and refer patients to approved specialists. Generally the HMO will not, without prior approval, cover medical expenses incurred by seeing someone who is not contracted with the HMO. Usually an HMO will have defined coverage for emergency medical care when one travels outside its coverage area.

In contrast to the HMO, the PPO allows one to see any doctor one wishes. One does not have to designate a primary care physician, and one can usually see any specialist without referral. The PPO offers choice and flexibility, but is often more expensive.

Most PPOs have a preferred provider list, much like the HMO provider list. Usually, seeing someone on the list means less expense. In fact, the PPO basically has an HMO component and network built into it.

A person who chooses to stay within the preferred provider list makes co-payments for services. It almost always costs less to obtain service from a preferred provider or “network” physician or facility. As well, a PPO often has two different sets of deductibles. Deductible payments for preferred providers tend to be much lower than for those out of network.

In some areas, out of network services may also cost more than in network services because the PPO determines “reasonable cost” of a physician or hospital’s fees. In other words, they may cover 80% of the reasonable costs, which means if the physician or hospital charges more than “reasonable cost, one can spend much more than 20% or greater of the bill.

Further, the PPO is quite inflexible about changing rules when it comes to using services outside the network. One is welcome to do so, but will pay a higher price, even if the preferred provider list cannot offer a similar service. However, some prefer the flexibility of the PPO to the limited coverage aspects of the HMO.

Frequently, employees are not really given a choice as to what insurance they can get. However, when given a choice, they usually have the choice between either an HMO or a PPO. Depending upon one’s health needs, and income level, the PPO may ultimately be a better choice because it does provide access to a greater number of doctors and facilities. It is wise to ascertain the number of network physicians and facilities offered in PPO plans. Some HMO plans may be better deals when the HMO contracts with more providers than does a PPO.

What is an HMO and Managed care plans?

What is an HMO?

Health Maintenance Organization - HMO's are both insurers and health care providers. They accept responsibility for a specific set of health care benefits offered to customers and provide those benefits through a network of physicians and hospitals.


Many people today are using HMO's. According to a New York Times article (Freudenheim, M. "Health Care in the Era of Capitalism," New York Times, April 2, 1996), an estimated 58 million Americans are enrolled in HMO's, and another 81 million are enrolled in other types of managed care. A July 8, 1996 Reuter's article says that more than 4 million Medicare beneficiaries and 12 million Medicaid recipients are in HMO's and other managed-care plans.

What kinds of HMO's are there? Staff model HMO's own and operate physician-staffed health centers that offer a broad range of medical care including laboratory, x-ray, vision, and pharmacy services.


Group practice HMO's contract with medical groups to provide health services to HMO members.

group model HMO

A health maintenance organization (HMO) that contracts with a group of physicians with multiple specialties who are employees of the group practice. Also known as a group practice model HMO.

health maintenance organization (HMO)

A healthcare system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.

health promotion programs

Programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes. Also known as preventive care programs or wellness programs.

Indemnity and Traditional Insurance

Traditional insurance, also known as Indemnity or Fee-for-Service, allows members to select any healthcare provider for services. Traditional insurance offers the most freedom of choice and control over healthcare, but benefits are maximized when using a participating Blue Cross Blue Shield company.

managed care

The integration of financing and delivery of healthcare within a system that seeks to manage the accessibility, cost and quality of that care.

managed dental care

Any dental plan offered by an organization that provides a benefit plan that differs from a traditional fee-for-service plan.

medical advisory committee

The MCO (managed care organization) committee that evaluates proposed policies and action plans related to clinical practice management, including changes in provider contracts, compensation and changes in authorization procedures. Medical advisory committees also review data regarding new medical technology and examine proposed medical policies.

network model HMO

A health maintenance organization (HMO) that contracts with multiple group practices of physicians or specialty groups

Description Common Resolutions 

0453 Enrolled in HMO or an Encounter Claim for F. F. S. Verify the enrollee eligibility and bill the claim to the appropriate carrier.

MANAGED CARE

Managed Care can be a type of company or type of plan offered by company.

Managed Care Companies: Are both for profit and non profit companies, which offer only managed care plans. It is financed by premiums and sell both group and individual plans and only health insurance.

Managed Care Plan: There are three common types of managed care plans: Health Maintenance Organization, Point of Service Organization, and Preferred Provider organization. Each plan has a different balance of a patient’s cost for the plan. In general, the more choice a patient has of which provider he can see, the more expensive the plan.

Managed care is different from Commercial Insurance because it attempts to “manage a person’s care” by restricting the providers an enrollee can visit. Managed care usually has cheaper premiums than Commercial insurance.

The main emphasis of managed care is to control utilization of services to achieve appropriate, efficient use of resources along with positive outcomes. As a result, managed care organizations employ such strategies as pre-authorizations, re-authorizations, and on-going case review. Most often patient care under managed care is coordinated by a managed care case manager who may follow patients through all settings or just specific settings.

HEALTH MAINTENANCE ORGANIZATION (HMO)

HMO consists of a network of physicians, hospitals, and other healthcare providers that have contracted with an insurance company to manage an enrollee’s care. Services rendered by providers outside of network are not eligible for coverage. With an HMO plan, a patient must first refer a primary care physician (PCP); the PCP then manages the patient’s care and may refer that patient to other provider if necessary. HMO’s are generally the least expensive managed care plans for enrollees because this type of plan has the most restrictions on provider choice.

Pre Certification and Pre Authorization - Difference

Pre Certification


A requirement that you obtain the insurance company's approval before a medical service is provided. If you fail to follow the pre-certification procedures the company may reduce or deny claim payment. Please note: getting pre-certification does not guarantee claim payment. Also called Utilization Review.


A utilization management technique that requires a healthcare insurance plan member or the physician in charge of the member's care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.

Prior Authorization

Prior authorization is a requirement that your physician obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval, your health plan may not provide coverage, or pay for, your medication.


In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review. See also precertification.

Both are similar.


preadmission testing

A utilization management technique that requires health insurance plan members who are scheduled for inpatient care to have preliminary tests, such as X-rays and laboratory tests, performed on an outpatient basis prior to admission.

primary source verification

A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.

Managed care plans

Managed care plans


Definition: Managed care plans are health-care delivery systems that integrate the financing and delivery of health care. Managed care organizations generally negotiate agreements with providers to offer packaged health care benefits to covered individuals.

Purpose: The purpose for managed care plans is to reduce the cost of health care services by stimulating competition and streamlining administration.



Three basic types of managed care plans exist: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans.

• Participants in HMO plans must first see a primary care provider, who may be a physician or an advanced practice registered nurse (APRN), in order to be referred to a specialist. The Independent Practice Association (IPA) contracts with physicians in private practice to see HMO patients at a prepaid rate per visit as a part of their practice.

• PPOs are more flexible than HMOs. Like HMOs, they negotiate with networks of physicians and hospitals to get discounted rates for plan members. But, unlike HMOs, PPOs allow plan members to seek care from specialists without being referred by a primary care practitioner. These plans use financial incentives to encourage members to seek medical care from providers inside the network.

• POS plans are a blend of the other types of managed care plans. They encourage plan members to seek care from providers inside the network by charging low fees for their services, but they add the option of choosing an out-of-plan provider at any time and for any reason. POS plans carry a high premium, a high deductible, or a higher co-payment for choosing an out-of-plan provider

Definition of Pre-Certification

A health plan's pre-certification (pre-authorization, prior authorization) process usually begins with a nurse employed by the health plan completing an initial review of the patient's clinical information, which is submitted by the practice, to make sure the requested service meets established guidelines. If it does, the nurse authorizes the request and the health plan will cover the service. If the service does not meet the guidelines, the nurse refers the case to the health plan's physician reviewer (usually the medical director or a physician consultant), who decides whether to approve or deny the request based on the information provided to the health plan. The physician reviewer may also "pend" the request and ask the physician for additional information before making a final decision.

The pre-certification process is one of the reasons physicians and patients are so dissatisfied with HMOs, which use this strategy more often than other managed care organizations in an effort to contain costs. The trade-off is that HMO premiums are usually lower than those of other managed care organizations that offer fewer restrictions (e.g., PPOs and POS plans). Although many health plans are finding less punitive ways to cut costs, such as using care coordination, some form of utilization management will always be used because it encourages both patients and physicians to make cost-effective decisions and abide by the plan's rules.

What is Pre-certification

What is pre-certification (pre authorization, prior authorization)?

Pre-Certification is an authorization given by your insurance company after you Initial Evaluation to each patient for a specified number of visits. Pre-Certification is not a guarantee of payment. It also requires to identify the service is medically necessary for outpatient hospital services in connection with medical, dental Procedures.

What is considered a pre-existing condition?

Preexisting Condition means a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the 6 months before the earlier of the:

• Effective date of coverage; or

• First day of the Waiting Period.

A pre existing condition is a medical condition that existed before you obtained health insurance. In most cases, there is a 9 month waiting period for pre existing medical condition coverage. That means that if a company offers you coverage, they may not provide coverage for that specific pre existing medical condition for 9 - 12 months.


In many cases, if have had coverage in place for at least 18 months with no more than a 63 day gap in coverage, and you are just switching insurance companies, the new company will give you credit for having coverage in place and waive the waiting periods for your conditions. This allows you to switch plans if you need to.

Remember, the idea for insurance is to protect yourself in case something bad happens. You don't buy car insurance to cover the cost of oil changes for your car, you buy it for the really bad things that can happen. The same is true for health insurance. You need to have it in place before something bad happens. You can't buy auto insurance after the accident to cover the cost of the accident. The same is true for health insurance

Preexisting Conditions Provision

Benefits for Eligible Expenses incurred for treatment of a Preexisting Condition will not be available during the twelve-month period following the Participant's initial Effective Date, or if a Waiting Period applies, the first day of the Waiting Period (typically the date you are hired).



The Preexisting Condition exclusion will not apply to:

1. A newborn child who is added as described in Dependent Enrollment Period within the first 31 days after the date of birth; or

2. A child who is adopted or involved in a suit for adoption before attaining the limiting age shown in the definition of Dependent and who applies, as described in Dependent Enrollment Period, for coverage under this Contract; or

3. A court ordered Dependent of a covered Employee who applies for coverage as described in Dependent Enrollment Period; or

4. An individual who was continuously covered for an aggregate period of twelve months under Creditable Coverage that was in effect up to a date not more than 63 days before the Effective Date of coverage under the Health Benefit Plan, excluding any Waiting Periods.

The Carrier will credit the time you were covered under Creditable Coverage if the previous coverage was in effect under a Health Benefit Plan or self-funded Health Benefit Plan at any time during the twelve months prior to the Effective Date of coverage under this Plan. If the previous coverage was issued under a Health Benefit Plan, any waiting period that applied before that coverage became effective also will be credited against the Preexisting Condition exclusion.

Pregnancy, conditions resulting from domestic violence, and genetic information without a diagnosis of a specific condition shall not be considered a Preexisting Condition. All other terms, provisions, limitations, and exclusions will apply to all Participants even if any Preexisting Condition exclusion is not applicable for the reasons set out above.

What is Pre-Authorization

Pre-authorization:

This is a requirement to be adhered to before the patient gets registered for treatment. Also known as pre-certification, this requires notification to the plan of certain planned services and all elective inpatient hospitalizations before they are rendered. Depending on the plan, either the patient or the provider must seek pre-authorization for these services. Certain managed care plans require the patients to go through a contracted physician participating in their network. If the patient gets treated through a physician not part of the network then the managed care plan require the physician to call the plan and notify them of the treatment before hand. Only after their approval can the treatment be proceeded. If the treatment is done without the approval, then the managed care plan will not reimburse the physician for their services nor can the physician bill the patient. This approval is called pre-authorization and a copy of this should be made available in the patient’s file before the treatment is rendered. Another requirement is to obtain a second opinion from an impartial physician regarding medical necessity of the procedure to be performed.


A service is deemed medically necessary when-

• It is appropriate for the diagnosis being reported.
• It is provided in the appropriate location.
• It is not provided for the patient’s or his/ her family’s convenience.
• It is not custodial care. (Custodial care is care that can be provided by people who are not trained medical professionals.)


Once the authorization has been granted, an authorization # would be given. This number should be reported on the claim for the service.


Preauthorization Requirements

Preauthorization establishes in advance the Medical Necessity or Experimental/Investigational nature of certain care and services covered under this Plan. It ensures that the Preauthorized care and services described below will not be denied on the basis of Medical Necessity or Experimental/Investigational. However, Preauthorization does not guarantee payment of benefits. Actual availability of benefits is always subject to other requirements of the Plan, such as Preexisting Conditions, limitations and exclusions, payment of premium, and eligibility at the time care and services are provided.

The following types of services require Preauthorization:

• All inpatient Hospital Admissions,

• Extended Care Expense,

• Home Infusion Therapy,

• All inpatient treatment of Chemical Dependency, Serious Mental Illness, and Mental Health Care,

• If you transfer to another facility or to or from a specialty unit within the facility.

• The following outpatient treatment of Chemical Dependency, Serious Mental Illness, and Mental Health Care:

- Psychological testing;

- Neuropsychological testing;

- Electroconvulsive therapy;

- Intensive Outpatient Program.

Intensive Outpatient Program means a freestanding or Hospital-based program that provides services for at least three hours per day, two or more days per week, to treat mental illness, drug addiction, substance abuse or alcoholism, or specializes in the treatment of co-occurring mental illness with drug addiction, substance abuse or alcoholism. These programs offer integrated and aligned assessment, treatment and discharge planning services for treatment of severe or complex co-occurring conditions which make it unlikely that the Participants will benefit from programs that focus solely on mental illness conditions.

You are responsible for satisfying Preauthorization requirements. This means that you must ensure that you, your family member, your Physician, Behavioral Health Practitioner or Provider of services must comply with the guidelines below. Failure to Preauthorize services will require additional steps and/or benefit reductions as described in the paragraph entitled Failure to Preauthorize.

Preauthorization for Inpatient Hospital Admissions

In the case of an elective inpatient Hospital Admission, the call for Preauthorization should be made at least two working days before you are admitted unless it would delay Emergency Care. In an emergency, Preauthorization should take place within two working days after admission, or as soon thereafter as reasonably possible.

To satisfy Preauthorization requirements, on business days between 7:30 a.m. and 6:00 p.m. Central Time, you, your Physician, Provider of services, or a family member should call one of the Customer Service toll-free numbers listed on the back of your Identification Card. After working hours or on weekends, please call the Medical Preauthorization Helpline toll-free number listed on the back of your Identification Card. Your call will be recorded and returned the next working day. A benefits management nurse will follow up with your Provider's office. All timelines for Preauthorization requirements are provided in keeping with applicable state and federal regulations.



In-Network Benefits will be available if you use a Network Provider or Network Specialty Care Provider. If you elect to use Out-of-Network Providers for services and supplies available In-Network, Out-of-Network Benefits will be paid. In-Network and Out-of-Network Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied.


However, if care is not available from Network Providers as determined by BCBSTX, and BCBSTX authorizes your visit to an Out-of-Network Provider to be covered at the In-Network Benefit level prior to the visit, In-Network Benefits will be paid; otherwise, Out-of-Network Benefits will be paid.

When an inpatient Hospital Admission is Preauthorized, a length-of-stay is assigned. If you require a longer stay than was first Preauthorized, your Provider may seek an extension for the additional days. Benefits will not be available for room and board charges for medically unnecessary days.

Preauthorization not Required for Maternity Care and Treatment of Breast Cancer Unless Extension of Minimum Length of Stay Requested

Your Plan is required to provide a minimum length of stay in a Hospital facility for the following:

• Maternity Care

- 48 hours following an uncomplicated vaginal delivery

- 96 hours following an uncomplicated delivery by caesarean section

• Treatment of Breast Cancer

- 48 hours following a mastectomy

- 24 hours following a lymph node dissection

You or your Provider will not be required to obtain Preauthorization from BCBSTX for a length of stay less than 48 hours (or 96 hours) for Maternity Care or less than 48 hours (or 24 hours) for Treatment of Breast Cancer. If you require a longer stay, you or your Provider must seek an extension for the additional days by obtaining Preauthorization from BCBSTX.

Preauthorization for Extended Care Expense and Home Infusion Therapy
Preauthorization for Extended Care Expense and Home Infusion Therapy may be obtained by having the agency or facility providing the services contact BCBSTX to request Preauthorization. The request should be made:

• Prior to initiating Extended Care Expense or Home Infusion Therapy;

• When an extension of the initially Preauthorized service is required; and

• When the treatment plan is altered.

BCBSTX will review the information submitted prior to the start of Extended Care Expense or Home Infusion Therapy and will send a letter to you and the agency or facility confirming Preauthorization or denying benefits. If Extended Care Expense or Home Infusion Therapy is to take place in less than one week, the agency or facility should call the BCBSTX Medical Preauthorization Helpline telephone number indicated in this Benefit Booklet or shown on your Identification Card.

If BCBSTX has given notification that benefits for the treatment plan requested will be denied based on information submitted, claims will be denied.

Preauthorization for Chemical Dependency, Serious Mental Illness, and Mental Health Care
In order to receive maximum benefits, all inpatient treatment for Chemical Dependency, Serious Mental Illness, and Mental Health Care must be Preauthorized by the Plan. Preauthorization is also required for



certain outpatient services. Outpatient services requiring Preauthorization include psychological testing, neuropsychological testing, Intensive Outpatient Programs and electroconvulsive therapy. Preauthorization is not required for therapy visits to a Physician, Behavioral Health Practitioner and/or Professional Other Provider.

To satisfy Preauthorization requirements, you, a family member, or your Behavioral Health Practitioner must call the Mental Health/Chemical Dependency Preauthorization Helpline toll-free number indicated in this Benefit Booklet or shown on your Identification Card. The Mental Health/Chemical Dependency Preauthorization Helpline is available 24 hours a day, 7 days a week. All timelines for Preauthorization requirements are provided in keeping with applicable state and federal regulations.

In-Network Benefits will be available if you use a Network Provider or Network Specialty Care Provider. If you elect to use Out-of-Network Providers for services and supplies available In-Network, Out-of-Network Benefits will be paid. In-Network and Out-of-Network Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied.


However, if care is not available from Network Providers as determined by BCBSTX, and BCBSTX authorizes your visit to an Out-of-Network Provider to be covered at the In-Network Benefit level prior to the visit, In-Network Benefits will be paid; otherwise, Out-of Network Benefits will be paid.

When treatment or service is Preauthorized, a length-of-stay or length of service is assigned. If you require a longer stay or length of service than was first Preauthorized, your Behavioral Health Practitioner may seek an extension for the additional days or visits. Benefits will not be available for medically unnecessary treatment or services.

Failure to Preauthorize

If Preauthorization for inpatient Hospital Admissions, Extended Care Expense, Home Infusion Therapy, all inpatient and the above specified outpatient treatment of Chemical Dependency, Serious Mental Illness and Mental Health Care is not obtained:

• BCBSTX will review the Medical Necessity of your treatment or service prior to the final benefit determination.

• If BCBSTX determines the treatment or service is not Medically Necessary or is Experimental/Investigational, benefits will be reduced or denied.

• You may be responsible for a penalty in connection with the following Covered Services, if indicated on your Schedule of Coverage:

- Inpatient Hospital Admission

- Inpatient treatment of Chemical Dependency, Serious Mental Illness, or Mental Health Care.

The penalty charge will be deducted from any benefit payment which may be due for the Covered Services.

If an inpatient Hospital Admission, Extended Care Expense, Home Infusion Therapy, any treatment of Chemical Dependency, Serious Mental Illness, and Mental Health Care or extension for any treatment or service described above is not Preauthorized and it is determined that the treatment, service, or extension was not Medically Necessary or Experimental/Investigational, benefits will be reduced or denied.