CurrentBaylor Scott & White Health PlanPolicy N/A

Individual Preferred Provider Organization (PPO) Insurance Policy

This document governs the terms, benefits, member rights, and administrative provisions of an individual PPO insurance plan issued by Baylor Scott & White Insurance Company and affects Subscribers and Covered Dependents (members) under the plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyIndividual Preferred Provider Organization (PPO) Insurance Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must contact the authorization phone number on the Member ID card at least three calendar days prior to admissions or scheduled services that require preauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10day free-look period for subscribers

26age of ineligibility for dependents

100%in-network coverage after OOP

72hexpedited appeal decision timeframe

12preexisting condition limit

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Limits

Coverage criteria and administrative rules

Coverage criteria and administrative rules governing covered services, definitions, member financial responsibilities, utilization review, preauthorization, continuity of care, and exclusions. Consolidated key rules and operational notes below.

Definitions: key terms used in coverage determinations: Deductible Family Maximum, Diabetes Equipment/Supplies, Preauthorization, Preexisting Condition, Preventive Care, Post-Acute Transition, and Post-Stabilization are defined and used to determine coverage and waiting periods. (See Definitions for full text.)

Member financial responsibility: Required Payments (Premiums, Copayments, Coinsurance, Deductibles) are due as specified in the Schedule of Benefits. Copayments and Coinsurance are generally due at time of service. Maximum Out-of-Pocket rules apply as stated; certain payments (e.g., specialty drug copayments on Formulary Level 4, Rider payments) may not count toward the Maximum Out-of-Pocket. Cash payments to providers may be credited toward Deductible/Max OOP when criteria met.

Preauthorization and Utilization Review: The Plan operates a Utilization Review program that includes Preauthorization (prospective), Admission review, Continued stay review, Retrospective review. Certain services require Preauthorization to be covered; failure to obtain Preauthorization when required may result in denial or reduction of benefits and additional Member charges which may not count toward Deductible or Max OOP.

Preauthorization timing and process: Participating Providers or Members should contact the authorization phone number on the Member ID Card during business hours at least three (3) calendar days prior to admission or scheduled service requiring Preauthorization where feasible. For Emergency admissions, notify the Plan within forty-eight (48) hours or as soon as reasonably possible. The Plan will notify the ordering Participating Provider in writing within three (3) days if a service is determined not Medically Necessary and provide clinical basis, reasons, criteria sources, and Appeal instructions.

Review timeframes and notices: Continued stay determinations are communicated to provider within 24 hours (phone/electronic) and in writing within 3 working days. Retrospective adverse determinations will be provided in writing no later than 30 days after receipt of the claim (with possible 15-day extension when criteria met). Failure by the Plan to render determinations within required timeframes is treated as an Adverse Determination and is appealable.

Internal appeals and expedited review: Members have 180 days to file an internal Appeal of an Adverse Determination. The Plan will acknowledge Appeals within 5 working days and decide within 30 calendar days (72 hours or sooner for expedited/urgent matters). Expedited Appeals (life-threatening, urgent, continued hospitalization, certain drug/infusion issues, step therapy exceptions) will be decided within 72 hours or sooner as specified.

Continuity of care / Transitional coverage: A Member is a continuing care patient if receiving treatment from a Participating Provider for serious/complex condition, pregnancy, institutional/inpatient course, nonelective surgery (including post-op care), or terminal illness. When a Participating Provider's contract terminates (other than for fraud), the Member will be notified and given the opportunity to elect transitional coverage from that Provider. Transitional coverage continues until the earlier of 90 days after notice or when the Member no longer qualifies; for terminal illness the period is nine (9) months.

Preventive care and USPSTF/HRSA/CDC-based services: Preventive Care items and services recommended with an 'A' or 'B' USPSTF grade, HRSA-supported guidelines for infants/children/adolescents and women, and CDC/ACIP immunizations are covered without Copayment, Coinsurance, or Deductible when provided in-network, subject to applicable statutory/regulatory updates.

Biomarker testing coverage conditions: Biomarker testing for diagnosis, treatment, management, or monitoring is covered when supported by FDA labeling or approval, an indicated drug's companion test, CMS national/local coverage determinations, consensus statements, or nationally recognized clinical practice guidelines.

Exclusions and administrative limits: The Policy enumerates numerous exclusions (non-covered services) and limits including but not limited to: elective abortions (unless medically necessary), gender alteration treatments, cosmetic procedures except when reconstructive/medically necessary as defined, chiropractic care, dental care, custodial care, experimental or investigational treatments, routine foot care, many vision and dental items, infertility treatments (unless Rider), most mental health and chemical dependency services (except where specified), household equipment/fixtures, weight reduction services, work-related injuries (see Exclusions for full list).

Operational notes and member obligations: Members must follow claim filing procedures (timely submission of claims and required documentation), cooperate with the Plan's subrogation and reimbursement rights, and notify the Plan for COB and coordination of benefits situations. Failure to timely provide requested information may toll review periods and affect determinations.

Coding and Code-Based Notes

Diabetes-related itemsmixedCovered

Diabetes Equipment means blood glucose monitors, insulin pumps and associated attachments, insulin infusion devices, and podiatric appliances; Diabetes Supplies means test strips, lancets, insulin and insulin analogs, injection aids, syringes, oral agents, and glucagon emergency kits. New or improved diabetes equipment and supplies approved by the FDA shall be covered if determined Medically Necessary by a Participating Provider through a written order.

Not specified in this sectionmixed

No specific CPT/HCPCS/ICD-10 codes are specified in this section; text addresses Issuer's right to contract with providers and related provider relationship terms.

mixed

Document title and policy type; no specific procedure or billing codes provided in this header chunk.

Mammography modalitiesmixedCovered

Screenings provided by Low-Dose Mammography, Digital Mammography, and Breast Tomosynthesis; annual screening mammography for female members age 35+ and diagnostic imaging no less favorable than screening mammogram.

Preventive screening testsmixed

Covered preventive tests include mammography screening modalities, FDA-approved Pap/HPV testing (conventional or liquid-based cytology alone or with FDA-approved HPV test) for women 18+, and FDA-approved ovarian cancer detection tests including CA-125 once every 12 months for women 18+.

DME and prescription routingmixed

Durable Medical Equipment, orthotic and prosthetic devices covered when Medically Necessary as determined by Medical Director in consultation with treating physician; prescription drug coverage depends on drug type, setting, and presence of Prescription Drug Rider (pharmacy vs medical benefit routing described).

Outpatient radiology examplesmixed

Examples include CT scans, angiograms (excluding cardiac angiograms), MRIs, myelography, stress tests with radioisotope imaging, and PET scans; covered when Medically Necessary and authorized by a Participating Provider.

Referenced services without codesmixed

Newborn hearing screening (birth through age 2) and cardiovascular noninvasive screening tests (carotid ultrasound, CT coronary calcium scoring) described; no explicit CPT/HCPCS codes provided in these sections.

Coding guidancemixed

Sections note exclusions and coverage scope for prescription drugs and related supplies; no specific billing or procedure codes provided. Guidance includes pharmacy benefit exclusions and conditions for office-administered drugs requiring prior approval.

COB definitionsmixed

Definitions relevant to Coordination of Benefits: 'plan' (lists plan types), 'allowable expense' rules for negotiated vs non-negotiated fees, and 'allowed amount' defined as carrier-determined covered billed charge; no procedure codes listed.

Colorectal cancer screeningmixedCovered

Coverage for colorectal cancer screening for average-risk members age 45+ including initial colonoscopy or other USPSTF A/B tests and follow-up colonoscopy if initial results are abnormal; no specific billing codes listed in text.

Prostate cancer screeningmixedCovered

Annual medically recognized diagnostic exam for detection of prostate cancer including PSA and physical exam for males age ≥50, or ≥40 with family history or risk factor; text does not provide explicit CPT/HCPCS codes.

Mastectomy and reconstructive surgerymixedCovered

Coverage includes minimum inpatient stays (24 hours after lymph node dissection; 48 hours after mastectomy), reconstructive surgery after mastectomy including contralateral surgery for symmetry, prostheses and treatment of complications as required by federal and Texas law; no specific procedure codes provided.

Preventive screenings (descriptive)mixed

Descriptive listing of preventive screening services: prostate, colorectal, cervical/HPV, and ovarian cancer screening tests with age and frequency criteria per state and USPSTF guidance; sections do not list specific billing codes.

Pharmacy coding notesmixed

Pharmacy provisions describe formulary tiers, copayment structures, specialty drug dispensing requirements, preauthorization rules, and conditions for covering non-formulary drugs; no explicit CPT/HCPCS/NDC codes are provided in these sections.

Preauthorization renewal window

Preauthorization renewal windowRenewal requests may be submitted beginning 60 days before the existing authorization expires.

Review objectiveWe will review the renewal request and, to the extent possible, issue a determination before the existing authorization expires.

Related processApplies to benefits that require Preauthorization as part of the Utilization Review program (preauthorization, admission, retrospective, continued stay reviews).

Provider Requirements, Authorization, and Claims

Prior Authorization

IFSP Submission for Developmental Delays

The Plan requires submission of the Individualized Family Service Plan (IFSP) for children with Developmental Delays before any related services are provided and again whenever the IFSP is changed. Providers must ensure an IFSP is on file to support coverage for physical, occupational, speech, and dietary/nutritional evaluations and services furnished under the developmental delays benefit.

Prior Authorization

Hospital Admission Notification; Prosthetic Preauthorization

Members admitted to a Non‑Participating Hospital must notify the Plan within forty‑eight (48) hours of admission or as soon thereafter as reasonably possible. Failure to provide timely notification may result in denial of payment unless it was not reasonably possible to provide notice. Certain prosthetic devices require prior authorization; providers and members should contact the Plan to confirm whether a prosthetic device requires Preauthorization before procurement or fitting.

Prior Authorization

Key Definitions

Selected defined terms

Age of IneligibilityAge of Ineligibility for dependents under this Policy is 26.

Adverse DeterminationAn Adverse Determination is a Utilization Review agent's determination that requested or provided care is not Medically Necessary, appropriate, or is Experimental/Investigational.

Clinician-Administered DrugA Clinician-Administered Drug is an outpatient prescription drug that is not self-administered and is typically administered in a physician's office.

Copayment / Coinsurance / Covered ExpensesCopayment and Coinsurance are defined in the Schedule of Benefits; Covered Expenses are expenses for covered benefits and differ for Participating vs Non-Participating Providers and are subject to Deductibles and limits.

Complaint

Complaint — definition

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyIndividual Preferred Provider Organization (PPO) Insurance Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must contact the authorization phone number on the Member ID card at least three calendar days prior to admissions or scheduled services that require preauthorization.

SourceLink

On This Page

Preexisting condition exclusion duration

Preexisting condition exclusion durationBenefits for treatment of a preexisting condition are excluded for 12 months from a Member's Effective Date.

Exceptions — creditable coverageLimitation does not apply if Member had continuous Creditable Coverage for an aggregate of 18 months ending no more than 63 days before the Effective Date; prior coverage reduces the exclusion period.

DependentsPreexisting condition limitation does not apply to Covered Dependents age 18 and under.

Maximum Out-of-Pocket threshold

Maximum Out-of-Pocket thresholdMember's Maximum Out-of-Pocket is the amount shown on the Schedule of Benefits; once reached, in-network covered benefits are covered at 100%.

What counts toward OOPQualifying Out-of-Pocket Expenses count toward the Maximum Out-of-Pocket as described in the Schedule of Benefits; certain Rider payments and some specialty drug copayments may not count.

Credit for cash paymentsUnder specified conditions, cash payments made directly by a Member may be credited toward the Deductible and Maximum Out-of-Pocket — see BSWHealthPlan.com for procedures.

Contraceptive supply limits

Initial contraceptive supplyA three (3) month supply is covered when a covered prescription contraceptive drug is first prescribed.

Subsequent contraceptive supplySubsequent prescriptions of the same covered contraceptive drug are covered as a twelve (12) month supply.

Annual limit per plan yearA Member may obtain only one (1) twelve (12) month supply of a covered prescription contraceptive per Plan year.

Outpatient drug single-dose cost threshold

Outpatient drug single-dose cost thresholdOutpatient non-specialty drugs administered in an outpatient setting that cost $450 or more for a single dose may require Preauthorization by the Issuer.

ScopeApplies to non-specialty outpatient prescription drugs dispensed and administered in a Participating Provider's office or other outpatient setting.

ConsequenceDoses at or above this threshold may be subject to prior approval to be covered under the medical benefit.

Outpatient drug 12-month refill cost threshold

Outpatient drug 12-month refill cost thresholdRefillable outpatient prescriptions whose total cost during a 12-month period could equal or exceed $1,000 may require Preauthorization by the Issuer.

Applies toNon-specialty outpatient drugs dispensed and administered in outpatient settings; aggregate annual cost triggers prior authorization review.

Coverage impactWithout Preauthorization, coverage as part of the medical benefit may be excluded unless covered by a Prescription Drug Rider.

cardiovascular_screen_interval

Cardiovascular screening intervalNoninvasive atherosclerosis/artery function screening is available once every five (5) years.

Provider/lab requirementScreening must be performed by a laboratory certified by a recognized national organization.

Eligible testsIncludes carotid intima-media thickness ultrasonography and preauthorized CT coronary artery calcium scoring.

Coverage time limits

Coverage time limits — preexisting conditionsTreatment of a preexisting condition is excluded for 12 months from a Member's Effective Date unless exceptions apply (see Creditable Coverage rules).

Coverage time limits — prescription refillsInitial or refill prescriptions dispensed more than one (1) year after the date of the Physician's order are excluded from the Prescription Drug benefit unless covered by a Rider or prior approval.

Claim filing deadlineClaims for reimbursement should generally be submitted within 90 days of the date services were received; the Issuer has no obligation if claim is received more than 1 year after service except in certain circumstances.

Allowable expense cap

Allowable expense capWhen coordinating benefits, total benefits paid by all plans combined will not exceed the total allowable expense (100% of allowable expense).

Definition — allowable expenseAllowable expense includes health care expenses covered by any plan, including Deductibles, Coinsurance, and Copayments; expenses not covered by any plan are not allowable.

Facility of payment and recoveryThe COB administrator may treat payments made by another plan as benefits of this plan and may recover any excess payments under the COB rules.

Minimum inpatient hours after mastectomy

Minimum inpatient hours after mastectomyMinimum inpatient coverage of 48 hours following a mastectomy.

Minimum inpatient hours after lymph node dissectionMinimum inpatient coverage of 24 hours following a lymph node dissection.

Shorter staysThe minimum inpatient hours are not required if the Member and attending physician agree that a shorter period is appropriate.

Colorectal screening age threshold

Colorectal screening age thresholdColorectal cancer screening benefits are provided for members 45 years of age or older at average risk.

Included servicesIncludes initial colonoscopy or other screening tests and follow-up colonoscopy if initial results are abnormal; includes USPSTF A/B preventive services.

ApplicabilityApplies to average-risk members as described in the policy and Schedule of Benefits.

Prostate screening age threshold

Prostate screening age thresholdAnnual medically recognized prostate cancer exam and PSA test available for males age 50 and older, or age 40 and older with family history or other risk factors.

ComponentsCoverage includes a prostate-specific antigen (PSA) test and a physical examination for detection of prostate cancer.

Risk-based earlier screeningMembers with a family history or other prostate cancer risk factors are eligible beginning at age 40.

Colorectal screening age threshold (duplicate)

Colorectal screening age (average-risk duplicate)Coverage for colorectal cancer screening begins at age 45 for average-risk members.

Services includedInitial and follow-up colonoscopy and other USPSTF A/B grade screening services for average-risk individuals.

ReferenceSee Schedule of Benefits and preventive services provisions for specifics on cost-sharing and test types.

Prostate screening age thresholds (duplicate)

Prostate screening age thresholds (duplicate)Annual prostate exam and PSA: recommended at age ≥50 for average-risk males; begin at ≥40 for those with family history or other risk factors.

Covered testsIncludes PSA test and medically recognized diagnostic examination performed per plan rules.

Policy sourceState-mandated coverage language (Texas) requiring these age thresholds and covered services.

Maximum benefit for cardiovascular screening every 5 years

Maximum benefit for cardiovascular screening every 5 yearsMaximum benefit per Member every 5 years for cardiovascular disease screening tests is $200 (In-Network and Out-of-Network amounts listed in Schedule of Benefits).

FrequencyBenefit available once every five (5) years when screening is performed by a certified laboratory and meets eligibility criteria.

Cost-sharingCopayments/coinsurance as shown in the Schedule of Benefits apply (e.g., 30% in-network after deductible for specified tests).

Utilization Review and Preauthorization

Utilization Review & Preauthorization — placementUtilization Review includes preauthorization, admission, retrospective, and continued stay reviews; Preauthorization requirements and thresholds are documented in policy and Schedule of Benefits.

Provider actions cross-referenceProviders must submit Preauthorization requests per the Preauthorization Submission Requirements and contact the authorization phone number on the Member ID Card at least three calendar days prior to scheduled services when required.

Appeals interactionAdverse Determinations arising from Utilization Review are subject to internal appeal and Independent Review Organization processes as described in the policy.

Home Infusion and Prosthetic Authorization and Benefit Routing

Home infusion therapy and some prosthetic devices require Issuer approval as Medically Necessary prior to coverage. Home infusion benefits include pharmacy administrative/professional services, supplies and equipment directly related to infusion (excludes unrelated DME and professional services). Specialty drugs administered via home infusion are governed by the Specialty Drug benefit and applicable copay/authorization rules. Prior authorization inquiries should identify benefit routing (Specialty Drug benefit vs. Medical benefit) so claims are processed under the correct benefit.

Prior Authorization

Specialty Drug Prior Authorization

Outpatient Specialty Drugs listed on the Plan Formulary may require prior authorization by the Medical Director. Providers should verify specialty drug status and obtain preauthorization when required. Non‑preferred specialty drug copayments do not count toward the Maximum Out‑of‑Pocket.

Note

Cardiovascular Screening Authorization Note

Certain cardiovascular screening tests (e.g., carotid intima‑media ultrasonography, coronary artery calcium CT) are covered once every five years when performed by a nationally certified laboratory and, where applicable, are Preauthorized as Medically Necessary. Confirm age, risk factors, and preauthorization requirements before scheduling.

Prior Authorization

Prescription Prior Approval Requirements

Some outpatient, non‑specialty prescription drugs administered in an outpatient or office setting require prior approval if a single dose costs $450 or more, or if refillable prescriptions could total $1,000 or more over 12 months. Additionally, certain non‑specialty drugs dispensed by a pharmacy and administered in an office require Issuer approval to be covered under the Medical Benefit. Providers should submit documentation to the Issuer demonstrating medical necessity when requesting approval.

Documentation Required

Participant Notification and Cooperation

Plan participants must immediately notify the Plan Sponsor of any third‑party (including other insurers) who may be responsible for illness or injury and must cooperate with the Plan's recovery, subrogation, and reimbursement efforts. Participants must provide information about anticipated future treatment, execute authorizations, and obtain Plan consent before settling claims that involve the Plan's rights.

Note

Facility of Payment / Coordination of Benefits

Facility of payment/coordination of benefits: if another plan pays amounts that should have been paid by this Plan, the entity administering COB may pay that other payer and treat that amount as though it were paid under this Plan. The reasonable cash value of services provided is considered a payment when services are furnished.

Denial Risk

Recovery of Overpayments

Right of recovery: If the Plan (or its COB administrator) pays more than it should have under the COB rules, it may recover the excess from any person or organization it has paid or from any party responsible for benefits or services provided to the Member. Recovery may include the reasonable cash value of services.

Billing Rule

Assignment / Direct Payment to Providers

Assignment and direct payment: benefits are personal and not assignable by a Member. However, the Issuer may make direct payment to a Hospital, Physician, or other provider when there is an agreement in effect between the Issuer and the provider, when directed by law for emergency care, or when payment relates to specialty or other services at the Issuer's request because network services are unavailable.

Complaint is any oral or written expression of dissatisfaction with any aspect of the Issuer's operation, excluding dissatisfaction with an Adverse Determination or promptly resolved misunderstandings.

Examples includedMay include issues with plan administration, denial/reduction/termination for reasons not related to medical necessity, disenrollment decisions, or how a service is provided.

ExclusionsDoes not include disagreement with an Adverse Determination or swiftly resolved misunderstandings.

Covered Expenses

Covered Expenses — definitionCovered Expenses are the expenses incurred for covered benefits; amounts for Participating Providers will not exceed the contracted rate and for Non-Participating Providers will not exceed Usual and Customary rates.

Subject to limitsCovered Expenses are subject to applicable Deductibles and other benefit limits described in the Policy and Schedule of Benefits.

Expense dateAn expense is incurred on the date the Member receives the covered benefit; Covered Expenses may be less than the billed amount.

Medically Necessary

Medically Necessary — definitionMedically Necessary services are those clinically appropriate in type, frequency, extent, site, and duration, effective for the patient's condition and not primarily for convenience; determinations are subject to review by the Medical Director.

Decision authorityA Member's Participating or Non-Participating Provider's opinion of Medical Necessity is subject to review/approval by the Plan's Medical Director and Quality Assurance Committee.

ApplicationMedically Necessary requirement applies across inpatient, outpatient, DME, and other services eligible for coverage under the Policy.

Participating Provider / Non-Participating Provider

Participating Provider — definitionParticipating Providers have contracted with the Issuer to provide covered benefits and are listed by the Issuer; they accept Issuer payment as payment in full per contract terms.

Non-Participating Provider — definitionNon-Participating Providers have not contracted with the Issuer; use of such providers may result in additional Member charges and different payment rules, except for emergency care or certain facility exceptions.

Member recommendationMembers are strongly encouraged to use Participating Providers to assure highest quality and lowest cost under the Plan.

Experimental or Investigational

Experimental or Investigational — definitionTreatment judged by the Medical Director as not proven successful; determinations rely on peer-reviewed literature, FDA/HHS communications, IRB records, and other specified evidence sources.

AppealabilityDenials based on Experimental/Investigational determinations are Adverse Determinations and subject to internal Appeal and Independent Review Organization procedures.

Evidence consideredIncludes informed consent communications, well-conducted investigations in peer-reviewed literature, FDA publications, and institutional review board records.

Our Right to Contract with Providers

Our Right to Contract with ProvidersThe Issuer may contract with providers deemed able to reasonably provide covered benefits; Participating Providers are independent contractors and the Issuer is not their agent.

No agency relationshipParticipating Providers are independent and Subscribers/Members are not agents of the Issuer or its providers; Participating Providers determine treatment methods.

LimitationsTreatment prescribed/authorized by a Participating Provider is not automatically guaranteed to be covered under the Agreement.

Medically Necessary — cross-reference

Medically Necessary — cross-referenceBenefits are available only if Medically Necessary as defined in the Definitions section of the Certificate of Coverage.

Policy applicationThis definition is the standard applied across claims, Utilization Review, and Medical Director determinations.

Appeals implicationAdverse Determinations based on Medical Necessity are appealable per the Internal Appeal and IRO processes.

Utilization Review

Utilization Review — definitionUtilization Review is the program to evaluate inpatient and outpatient Hospital and ASC admissions and specified non-emergency outpatient surgeries, diagnostic procedures, and other services; includes preauthorization, admission, retrospective, and continued stay reviews.

Review typesIncludes Preauthorization Review (prospective), Admission Review, Retrospective Review, and Continued Stay Review (concurrent).

Interaction with appealsAdverse Determinations from Utilization Review are subject to Internal Appeal and Independent Review Organization procedures.

Adverse Determination

Adverse Determination — definitionAn Adverse Determination is the Issuer's or Utilization Review organization's determination that requested or provided care is not Medically Necessary or is Experimental or Investigational.

Appeal rightsMembers may file an internal Appeal within 180 days of notice; denied Appeals may be reviewed by an Independent Review Organization under Texas law.

Notice contentIf Appeal is denied, notice will include clinical basis and Member's right to IRO review.

Final Internal Adverse Determination

Final Internal Adverse Determination — definitionA Final Internal Adverse Determination is an Adverse Determination upheld by the Issuer at the completion of internal review and Appeal.

IRO escalationA Member whose Final Internal Adverse Determination is upheld may seek Independent Review Organization review per Chapter 4202 of the Texas Insurance Code.

Issuer obligationsIssuer must provide relevant records and documents to the IRO within three business days of request and will assume payment for the review.

Medically Necessary — additional reference

Medically Necessary — additional referenceServices must meet the Plan's Medical Necessity criteria (clinically appropriate in type, frequency, extent, site, and duration) to be covered.

Review roleMedical Director and Quality Assurance Committee review and may determine whether services meet Medical Necessity standards.

Coverage effectNon-Medically Necessary services are not covered and may be subject to Adverse Determination and Appeals.

Qualified Individual

Qualified Individual — bone mass measurementIncludes postmenopausal women not on estrogen, individuals with vertebral abnormalities or history of fractures, those with primary hyperparathyroidism, those on long-term glucocorticoid therapy, or individuals monitored for osteoporosis therapy response.

BenefitQualified Individuals are eligible for medically accepted bone mass measurement for detection and risk assessment of osteoporosis.

PurposeUsed to detect low bone mass and determine fracture risk and to monitor therapy effectiveness.

Qualified Individual (duplicate)

Qualified Individual (duplicate)See Qualified Individual criteria for bone mass measurement: postmenopausal women not on estrogen, vertebral abnormalities, fracture history, primary hyperparathyroidism, long-term glucocorticoid therapy, or therapy monitoring.

Coverage implicationQualified Individuals qualify for bone mass measurement benefits under the Policy.

DocumentationOrders and supporting documentation should be consistent with Participating Provider and Medical Director determinations.

Hearing aid prescribing clinicians

Hearing aid prescribing cliniciansHearing aid prescriptions must be written by an otolaryngologist/otologist or an audiologist with appropriate credentials and performed at the direction of a qualified otolaryngologist when required.

Frequency limit for minorsOne (1) hearing aid in each ear every three (3) years for Members through age 18 (see hearing aid coverage limits).

Coverage limitsPlan may limit coverage to least expensive appropriate device that meets accepted medical standards; Member may choose more costly device and pay excess.

Specialty Drugs

Specialty Drugs — definition/placementSpecialty Drugs are outpatient prescription drugs designated on the drug Formulary as Specialty Drugs and are covered under the Specialty Drug benefit with specific copayments and possible preauthorization.

Dispensing requirementsMost Specialty Drugs under the pharmacy benefit must be dispensed from Participating Specialty Pharmacy Providers and may require Preauthorization by the Medical Director.

OOP treatmentCopayments for certain Non-Preferred Specialty Drugs may not count toward the Maximum Out-of-Pocket as specified in the Schedule of Benefits.

Organ and Tissue Transplants

Organ and Tissue Transplants — coverage conditionsTransplants are covered when not Experimental/Investigational, recipient is a Member, donated human organs/tissue or FDA-approved device are used, procedure is Preauthorized, and Member meets Medical Necessity and facility protocols.

Preauthorization and approvalsTransplant procedures must be Preauthorized and the Member approved by the Participating Facility and Medical Director; services coordinated through health services department.

LimitsCoverage limited to one initial transplant and one subsequent re-transplant due to rejection for each type of solid organ transplant.

Biomarker testing coverage conditions

Biomarker testing coverage conditionsCoverage for biomarker testing requires supporting medical and scientific evidence such as an FDA-approved drug indication, FDA-approved/cleared test labeling, CMS national/local coverage determinations, consensus statements, or nationally recognized clinical practice guidelines.

PurposeTesting covered for diagnosis, treatment, appropriate management, or ongoing monitoring when supported by the enumerated evidence types.

ReviewCoverage decisions use the listed evidence sources and may be subject to Utilization Review and Medical Director determination.

Telehealth/Telemedicine

Telehealth/Telemedicine parityTelehealth and telemedicine benefits are covered and subject to the same terms and conditions as in-person services; an in-person visit is not required.

Access informationAdditional information about Telehealth Services is available at BSWHealthPlan.com.

ApplicabilityCovered benefits provided via telehealth are evaluated under the same Medical Necessity, cost-share, and Utilization Review rules as in-person care.

Family Member services

Family Member services — definitionServices or supplies furnished by a physician or provider related to a Member who ordinarily dwells in the Member's household, or services for which the Member would have no legal obligation to pay absent insurance, are excluded.

ScopeExclusion applies to in-house family providers and services typically provided at no charge outside insurance contexts.

ImplicationSuch services are not Covered Expenses unless otherwise specified or covered by a Rider.

Infertility Diagnosis and Treatment

Infertility Diagnosis and Treatment — definitionInfertility services such as IVF, artificial insemination, GIFT, ZIFT, infertility drugs, donor gametes, surrogacy, and related services are excluded unless covered by a Rider.

Diagnostic proceduresDiagnostic procedures to determine cause of infertility are listed as examples in Family Planning but treatment is generally excluded unless Rider applies.

ExceptionsSpecific infertility-related services may be covered only if a Rider explicitly provides coverage.

Claim filing and review

Claim filing and review — definitionClaims must be submitted with written proof acceptable to the Issuer; claims generally must be received within 90 days of service, and no later than one year except in specified circumstances.

Reimbursement conditionsMember may be reimbursed for payments made to non-contracting providers (e.g., emergency) if proof and claim are acceptable and submitted within timeframes.

ExceptionsFailure to submit within 90 days does not invalidate reimbursement if it was not reasonably possible; claims still must be filed as soon as reasonably possible.

Plan recovery rights

Plan recovery rights — definitionThe Plan is subrogated to a participant's recovery rights to the extent of benefits provided and is granted a lien on proceeds from third-party recoveries; the Plan may recover overpayments and seek reimbursement from settlements, judgments, or other proceeds.

Participant obligationsParticipants must cooperate, notify the Plan Sponsor of potential third-party claims, execute authorizations, and obtain Plan consent before settling claims.

Enforcement actionsIf participant fails to reimburse, the Plan may offset future benefits, bring legal action, or take other actions necessary to protect its interests.

Plan / This plan / Allowable expense / Allowed amount / Closed panel plan

Plan / This plan / Allowable expense / Allowed amount / Closed panel plan — definitionsDefinitions clarify 'plan' scope, what 'this plan' means for COB, 'allowable expense' (expenses covered by any plan including Deductibles/Coinsurance/Copayments), 'allowed amount' (carrier's determined covered billed charge), and 'closed panel plan' (coverage primarily through contracted panel providers).

COB effectWhen this plan is secondary it may reduce benefits so combined plan payments do not exceed 100% of allowable expense; rules govern order of benefit determination.

Non-allowable expense examplesCertain differences such as private room differentials, amounts above negotiated fees, and benefit reductions for noncompliance are not allowable expenses per COB rules.

payment made

Payment made — definitionPayment made includes providing benefits in the form of services; treated as the reasonable cash value of benefits provided in services for Facility of Payment purposes.

Right of recovery — relatedIf payment under COB provisions is more than appropriate, the organization may recover excess from payees or responsible parties.

Facility of payment implicationPayments by other plans may be treated as though paid under this plan and adjustments or recoveries made accordingly.

Excess Payments / Overpayment

Excess Payments / Overpayment — definitionExcess Payments (Overpayments) are amounts paid by the Issuer that should not have been paid under the plan; the Issuer may recover such amounts and treat them as Required Payments.

Recovery remediesIssuer may demand return, reduce future benefits, or take legal action; prevailing party in enforcement may recover costs and attorney fees.

Member obligationFailure to remit Excess Payments may result in legal action by the Issuer.

Confidentiality

Confidentiality — definitionMember medical records and application information are held in confidence and disclosed only with Member authorization, as necessary to administer the Agreement, or as required by law.

Privacy referenceMore details on uses and disclosures available in the Issuer's Notice of Privacy Practices at BSWHealthPlan.com.

Permitted disclosuresDisclosure permitted with Member's express authorization, to carry out Agreement administration, or when required/authorized by law or court order.