This document is the Individual PPO insurance policy issued by Baylor Scott & White Insurance Company that defines member rights, covered benefits, enrollment, and plan administration for Subscribers and their Covered Dependents.
No material clinical or coverage changes in this revision.
10day examination/return period for new subscribers
60days advance notice for premium changes
26age of ineligibility for dependents
$500/50%penalty for failure to preauthorize
90dclaim receipt deadline (standard)
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.
12 monthspreexisting condition exclusion period
Coverage Framework, Criteria, Exclusions, and Claims
inv-01: Coverage framework and administrative procedures
Coverage is provided as Preferred Provider Organization (PPO) benefits and governed by this Policy, the Schedule of Benefits, any Riders, and the procedures described below.
Coverage is PPO and guaranteed-renewable subject to the Issuer's right to change Premium rates with 60 days advance written notice; Subscriber has a 10-day examination/return period after receipt of the Policy.
The Agreement consists of the Policy, accepted Enrollment Application, Schedule of Benefits, Riders, and attachments; no agent may modify except the Issuer President.
Members entitled to covered benefits per the Schedule of Benefits and Policy; Effective Date shown on Member ID card; Agreement continues one year unless terminated per policy.
Table of Contents references Preauthorization Review, Admission Review, Continued Stay Review, Retrospective Review, Failure to Preauthorize, Prescription Drugs and Intravenous Infusions, and Appeal of Adverse Determinations as administrative processes for utilization review and coverage determination.
inv-02: Coverage-related definitions
Definitions relevant to coverage determination and benefit administration (terms used to determine medical necessity, benefit application, and program rules).
Durable Medical Equipment (DME): equipment that can withstand repeated use, serves a medical purpose, is not useful absent illness or injury, and is appropriate for home use; all requirements must be met before an item is DME.
Medically Necessary / Medical Necessity: services that, in the opinion of the Member's Participating or Non-Participating Provider and subject to Medical Director review, are in accordance with generally accepted standards of medical practice, clinically appropriate in type/frequency/extent/site/duration, not primarily for convenience, and not more costly than alternatives likely to provide equivalent results.
Preauthorization: prospective Utilization Review by the Issuer or its Utilization Review agent required for proposed services as described in the Preauthorization Review provisions.
Routine Patient Care Costs (clinical trials): costs of Medically Necessary care provided under the Plan irrespective of clinical trial participation, excluding investigational products, trial management costs, non-covered services, and services inconsistent with standards of care.
inv-03: Provider coverage, payment, continuity, and utilization review rules
Rules governing provider payment, coverage from participating and non-participating providers, continuity protections, and utilization review obligations.
Members entitled to Medically Necessary covered benefits from Participating and Non-Participating Providers subject to the Schedule of Benefits and this Policy.
Participating Providers agree to bill the Issuer and accept as payment in full the least of billed charges, Usual and Customary Rate, or contractual amount; Members remain responsible for Copayments, Coinsurance, and Deductibles in the Schedule of Benefits.
Non-Participating Provider covered expenses limited to the lesser of actual billed charges, eligible billed charges per hospital manual, or Usual and Customary Rate; such services may be subject to penalties or additional Deductible; exceptions apply for emergency care and authorized non-network services.
If Medically Necessary services are not reasonably available from Participating Providers and prescribed by a Participating Provider, the Issuer may authorize Non-Participating Provider services upon approval by the Medical Director within a time appropriate to circumstances, not to exceed five business days after receipt of requested documentation; if approved, Issuer will pay at Participating benefit level and credit applicable out-of-pocket amounts toward Participating deductibles/MOOP.
inv-04: Appeals, utilization review, and coverage limits
Administrative rules for preauthorization failures, appeals, independent review, and preexisting condition limits.
Failure to Preauthorize: if a benefit requiring Preauthorization is not Preauthorized and determined not Medically Necessary, the benefit may be reduced or denied and the Member may be charged additional amounts that do not count toward Deductible or Maximum Out of Pocket.
Prescription drugs and intravenous infusions are subject to medical necessity determinations and may require Preauthorization as described in the Coverage of Prescription Drugs provisions.
Internal Appeal process: Member, authorized representative, or Provider may request an internal Appeal within 180 days of an Adverse Determination; Issuer acknowledges within 5 working days; standard appeals decided within 30 calendar days; expedited appeals (including certain drug/infusion matters and life‑threatening conditions) decided within 72 hours or 1 business day after receipt of necessary information; clinical peer reviewer of same/similar specialty will review appeals.
Independent Review Organization (IRO): after a Final Internal Adverse Determination, Member may request independent review under Chapter 4202; Issuer must provide relevant records and documents to the IRO within 3 business days; Issuer will comply with IRO determinations regarding Medical Necessity or Experimental/Investigational status.
inv-05: Coverage Criteria and Rules
Core coverage criteria and rules for medical services, clinician-administered drugs, emergency and urgent care, ambulance transport, preventive services, immunizations, and age-based cancer screenings.
Medical Services: Medically Necessary professional services from Participating and Non-Participating Providers are covered inpatient and outpatient; Medical Necessity determined by provider subject to Medical Director review; cost-sharing per Schedule of Benefits applies.
Clinician-Administered Drugs: coverage does not require use of a Participating Pharmacy for Members with chronic, complex, rare, or life-threatening conditions when the physician attests delay would increase risk and Member provides informed written consent; does not apply to hospital/hospital outpatient infusion centers.
Emergency Care: Emergency visits to Participating or Non-Participating Providers covered to same extent as Participating Provider; medically necessary emergency care from Non-Participating Providers reimbursed at Usual and Customary or agreed rate and Member held harmless for amounts beyond applicable Copayment or OOP that would have been paid if network providers were available; post-stabilization care requires Issuer approval within time appropriate to circumstances (not to exceed one hour from request).
Urgent Care: prompt treatment for non-life-threatening conditions is covered and subject to Copayment in Schedule of Benefits; hospitals/ERs are not considered Urgent Care unless designated.
inv-06: Coverage criteria and examples
Selected coverage criteria and examples for screenings, therapies, home services, hospice, family planning, fertility preservation, DME, consumables, orthotics, and prosthetics.
Prostate screening: annual diagnostic exam and PSA for males >=50 asymptomatic or >=40 with family history/risk factor.
Colorectal screening: medically recognized screening for Members >=45 at normal risk; includes USPSTF A/B tests and colonoscopy with follow-up if abnormal.
Osteoporosis screening: bone mass measurement covered for Qualified Individuals (postmenopausal women not on estrogen; vertebral abnormalities; primary hyperparathyroidism; history of fractures; long-term glucocorticoid therapy; monitoring approved osteoporosis therapy).
Mammography: annual screening mammography for females >=35; includes low-dose, digital, tomosynthesis and diagnostic imaging not less favorable than screening coverage.
Cervical/HPV screening: annual diagnostic exam for women >=18 including Pap smear and FDA-approved HPV tests alone or combined.
inv-07: Orthotic Device Coverage
Orthotic device coverage—scope and limitations.
Covered when Medically Necessary: initial orthotic device, professional fitting services, and replacement if not due to misuse or loss (includes orthopedic/corrective shoes, shoe inserts, arch supports, orthotic inserts, and ankle braces required for recovery after surgery); coverage limited to the most appropriate model as determined by the Participating Provider.
inv-08: Prosthetic Device Coverage
Prosthetic device coverage—scope and preauthorization note.
Covered when Medically Necessary and, in some cases, Preauthorized by the Medical Director: includes initial prosthetic device, professional fitting services, replacement not due to misuse or loss, and normal repairs; examples include artificial arms, legs, hands, feet, eyes, breast prostheses and surgical brassieres after mastectomy; coverage limited to the most appropriate model as determined by the Participating Provider.
inv-09: Hearing Device Coverage
Hearing aid and cochlear implant benefits, limitations, and preauthorization applicability.
Covered services include fitting, dispensing, ear molds, habilitation/rehabilitation, and treatment related to hearing aids and cochlear implants; for cochlear implants, external speech processor and controller replacements allowed every three years.
Limitations: one hearing aid per ear every three years for Members through age 18; hearing aid prescription must be written by specified qualified clinicians; Plan may limit coverage to the least expensive appropriate device when alternatives exist; Preauthorization may be required.
inv-10: Prescription Drug Benefit Determination
Prescription drug benefit determination—how inpatient, outpatient specialty, and certain outpatient non-specialty drugs are covered and when preauthorization applies.
Inpatient Prescription Drugs: drugs (including Specialty Drugs) administered while admitted are covered as part of the inpatient benefit with no additional Deductible, Coinsurance, or Copayment.
Outpatient Specialty Drugs: Formulary-designated Specialty Drugs are covered under the outpatient Specialty Drug benefit, subject to Specialty Drug Copayments and Deductibles in the Schedule of Benefits; Specialty Drugs may require Preauthorization by the Medical Director and Specialty Drug copays for non-preferred drugs do not count toward OOP.
Outpatient Non-Specialty Drugs Administered in Outpatient Setting: non-specialty drugs dispensed/administered in a Participating Provider's office are part of the Medical Benefit and generally require no additional copayment; however, non-specialty outpatient drugs costing >= $450 for a single dose or whose 12-month total cost may equal/exceed $1,000 may require Preauthorization by the Issuer.
Outpatient non-specialty drugs dispensed at a pharmacy and administered in-office require Issuer approval to be covered as Medical Benefit; without prior authorization they are excluded unless covered by a Prescription Drug Rider.
inv-11: Radiological/Diagnostic Exam Coverage
Outpatient radiology and diagnostic exam coverage rules.
Outpatient radiological and diagnostic examinations are covered as Medically Necessary when prescribed and authorized by a Participating Provider; Deductible, Coinsurance and/or Copayments per Schedule of Benefits apply; ultrasound or cardiac angiogram are not subject to radiology coinsurance/copayment but related office/outpatient surgery cost shares may apply.
inv-12: Metabolic Disorder Formula Coverage
Coverage for specialty dietary formulas for PKU and heritable metabolic diseases.
Coverage provided for specialty dietary formulas necessary to treat Phenylketonuria (PKU) or a Heritable Metabolic Disease when prescribed by a Participating Provider to the extent the Plan provides coverage for other drugs available upon Physician orders.
inv-13: Elemental Formula Coverage
Amino acid-based elemental formula coverage and conditions.
Medically Necessary Amino Acid-Based Elemental Formulas are covered when ordered by a Participating Provider for indicated diagnoses (IgE and non-IgE mediated multiple food protein allergies, severe FPIES, eosinophilic disorders with biopsy evidence, impaired absorption disorders); administration services covered; benefits limited to Calendar Year maximum in Schedule of Benefits and subject to applicable cost sharing.
inv-14: Transplant Coverage Criteria
Transplant coverage criteria and limits for solid organ and selected tissue transplants.
Transplants covered only if not Experimental/Investigational, donor tissue or FDA-approved device used, recipient is Member, procedure is Preauthorized, Member meets Medical Necessity criteria and facility protocols, services coordinated through health services department, and a Preauthorized transplant network is used when required.
Covered transplant-related benefits include imaging, labs, chemotherapy, radiation, Prescription Drugs, procurement costs, and complications; coverage of each solid organ transplant limited to one initial transplant and one re-transplant for rejection.
inv-15: Acquired Brain Injury Services
Acquired brain injury services covered when medically necessary.
Covered services include cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral/neuropsychological/neurophysiological testing and treatment, neurofeedback therapy, remediation, post-acute transition and community reintegration services, outpatient day treatment and post-acute care treatment; benefits determined on same basis as other physical conditions.
inv-16: Clinical Trial Routine Care Coverage
Clinical trial routine patient care coverage conditions and provider reimbursement rules.
Routine patient care costs in qualifying clinical trials for cancer or life‑threatening conditions are covered if trial meets specified federal or FDA-related criteria; Member cost-sharing (Deductible, Coinsurance, Copay) applies.
Issuer is not required to reimburse the Research Institute for routine patient care unless the Research Institute and each provider agree to accept Plan-established rates as payment in full; services that are part of the trial subject matter and customarily paid by the Research Institute are excluded; routine patient care by Non-Participating Providers is not covered.
Pediatric craniofacial reconstructive coverage for dependents under age 18.
Reconstructive surgery for Covered Dependents younger than 18 is covered to improve function or attempt to create a normal appearance of abnormal structures caused by congenital defects, developmental deformities, trauma, tumors, infection, or disease; cosmetic surgery excluded unless medically necessary; dental services not required unless Schedule of Benefits or dental rider applies.
inv-18: Selected Coverage Criteria
Selected coverage criteria and program rules for clinical trials, craniofacial treatment, diabetes, newborn hearing, cardiovascular screening, telehealth, and biomarker testing.
Clinical Trials: Routine patient care covered only if Research Institute and providers accept Plan-established rates; routine care by Non-Participating Providers not covered; Member cost-sharing applies.
Craniofacial treatment: reconstructive surgery covered for dependents <18 to improve function or attempt to create normal appearance; cosmetic surgery excluded unless medically necessary.
Diabetes care: coverage for diabetes self-management training, education, care management, equipment and supplies when medically necessary and prescribed by a Participating Provider; refills limited until reasonably due based on utilization.
Newborn hearing screening: screening and necessary follow-up care covered through dependent's second birthday; Copayment/Coinsurance apply but no Deductible or benefit maximums for newborn hearing screening/follow-up.
inv-19: Exclusions and Limitations
Enumerated exclusions and limitations that are not covered under this Policy segment unless otherwise noted.
Excluded services (examples)
Elective abortions not necessary to preserve a Member's health are excluded.
Procedures to alter physical characteristics or biologically determined sex (sex transformation/hermaphroditism treatments) are excluded.
Blood, blood plasma, and other blood products are excluded.
Non-medically necessary breast implants, implant removal and replacement are excluded.
Chiropractic services are excluded.
inv-20: Excluded Services and Special Rules
Comprehensive list of excluded services, special rules, and limitations (summary of categories and notable exclusions).
Excluded categories include elective treatments/surgeries and their complications; benefits beyond benefit maximums; Experimental or Investigational treatments; services by family members living in Member's household or without legal obligation to pay; most infertility treatments except as covered by Rider; certain contraceptives and reversal of sterilization; genetic testing; household equipment and fixtures; dental care except where Schedule/rider applies; mental health and chemical dependency care except organic brain disease; non-emergency care outside U.S.; amounts exceeding Usual and Customary Rates; organ transplants and post-transplant care when performed in or organs procured from countries known for forced organ harvesting; personal comfort items; routine physical/administrative exams; and preexisting condition limitations for 12 months from Effective Date (subject to Creditable Coverage exceptions).
Prescription drug specific exclusions: OTC drugs except insulin; experimental/investigational drugs; non-FDA approved drugs; cosmetic drugs; infertility drugs; vitamins not requiring prescription; prescriptions dispensed more than one year after physician order; drugs administered in facility; biological products; and prescriptions extending past termination of Agreement.
inv-21: Exclusions and Limitations
Additional stated exclusions, time limits, and coverage limitations applicable to Members.
Physical, psychiatric, psychological and other exams/reports for employment, licensing, insurance, educational, research, premarital/pre-adoptive, judicial/administrative, and similar non-medical purposes are excluded.
Preexisting Condition Exclusion: benefits for treatment of a preexisting condition are not paid for 12 months from Member Effective Date subject to Creditable Coverage exceptions and reductions.
Prescription Drugs: Over-the-counter drugs are not covered; coverage limited to FDA-approved prescribed products, Specialty Drugs per policy, certain non-specialty drugs administered in-office or outpatient settings, and some pharmacy-dispensed drugs when prior Medical Director approval obtained.
Refractive/vision corrective surgery, routine foot care (except related to systemic conditions), and TMJ services (except medically necessary diagnostics/surgery) are excluded or limited per policy.
inv-22: Reimbursement Rules
Principle governing reimbursement obligations.
No reimbursement by Issuer for services for which a Member would have no obligation to pay in absence of coverage under this Policy.
inv-23: Claims Filing and Appeals
Claims filing requirements, timing, and exceptions for reimbursement requests.
Claim Filing Procedure: Member should submit written proof and a Claim for payment to Issuer's office; submissions must be acceptable to Issuer, typically received within 90 days of benefit receipt; Member must have complied with Policy terms.
Failure to file within 90 days does not invalidate reimbursement if it was not reasonably possible to submit within that period and proof is filed as soon as reasonably possible; itemized receipts must include provider name/address, date of service, amount paid, and diagnosis; Issuer has no obligation if proof/claim not received within one year of service except as allowed by law.
inv-24: Claims and Reimbursement
Claims submission mechanics, interaction with other payors, and procedures for reimbursement when paying non-participating providers.
When a Member or Provider pays a non-participating provider, submit written proof and an itemized Claim to Issuer within required timeframes (typically within 90 days; no obligation if >1 year) with required documentation; Issuer will reimburse to the extent covered under the Agreement.
If Medicare is primary, Covered Expense calculations follow Medicare rules; Issuer will pay the difference between Allowable Expense and Medicare payment as applicable and charge amounts against benefit limits.
inv-25: Processing and Payment Timelines
Issuer obligations and timelines for claim processing and payment.
Acknowledgment: Issuer will acknowledge receipt of a Claim within 15 days and may request additional information.
Decision: Issuer will notify acceptance or rejection within 15 business days after receipt of all requested items; if extended, decision no later than 45 days after notice of need for additional time.
Payment: If claim accepted, Issuer will pay no later than 5 business days after notification of acceptance.
inv-26: Complaint and Appeal Process
Complaint intake and internal appeal procedures, timelines, and panel composition.
Complaint filing: Members, physicians, providers, or designated representatives may file a written Complaint within 180 days to dispute benefit/claim processing; Issuer acknowledges within 5 business days, provides a one-page form if complaint received orally, and resolves within 30 calendar days (emergency/continued hospitalization within 1 business day).
Appeal of complaints: if unsatisfied, Complainant may appear before an Appeal panel or submit a written appeal; Issuer acknowledges appeal within 5 business days; Appeal panel composed of issuer staff, a Participating Provider with relevant specialty, and a Member; panel members independent of prior decision; Issuer completes Appeals Process within 30 calendar days of receipt of written appeal.
inv-27: Subrogation, Recovery, and Assignment
Plan recovery, subrogation, lien, assignment, and rights when benefits paid and third-party recovery exists.
Subrogation/Lien: If Plan pays benefits for illness/injury caused by a third party, Plan is subrogated to participant's recovery rights to the extent of benefits paid and has a lien on proceeds of settlements, judgments, or other remuneration from listed sources (liability, uninsured/underinsured, no-fault, workers' comp, indemnity agreements, etc.), subject to applicable state law.
Right to Recovery: Plan may recover overpayments made in error, payments due to misrepresentation, or incorrect payments during Maximum Out of Pocket period by requiring return or reducing future benefits; Plan will send statements and attempt collection through reminder letters and calls.
Assignment: plan participant is deemed to have assigned recovery rights to the Plan upon receiving benefits; participant may not assign or settle rights against responsible parties without Plan's prior written consent.
Participant obligations and Plan remedies related to recovery and reimbursement from third-party payments.
Right to recovery and remedies: Plan may require return of overpayments or reduce future benefit payments until reimbursed; Plan will send monthly statements for incorrect payments during Maximum OOP period.
Assignment and participant duties: participant is considered to have assigned recovery rights to Plan; participant must notify Plan Sponsor and third parties of Plan's subrogation rights, cooperate in recovery, provide information, authorize Plan actions, and obtain Plan consent before settling claims.
If participant fails to reimburse Plan from settlements/judgments/insurance proceeds, Plan may reduce current or future benefits until fully reimbursed; Plan may bring actions on its own or participant's behalf and may cease benefits until required documents provided.
Obligations transfer to beneficiaries/heirs on participant death; participant agrees to include Plan as co-payer on settlement drafts.
inv-29: Coordination of Benefits (COB)
Coordination of Benefits (COB) rules and order-of-benefit determination when multiple plans apply.
COB applies when an individual has coverage under more than one plan; the primary plan pays first and the secondary plan may reduce benefits so combined payments do not exceed allowable expenses.
Order-of-benefit determination rules: primary pays per its terms; a plan without compliant COB provisions is primary unless specified; special rules include nondependent vs dependent, birthday rule for dependent children, divorced/separated parent rules including court orders and custodial parent hierarchy, active vs retired employee rule, COBRA/state continuation rule, and length-of-coverage rule; if rules do not determine order, plans share equally.
If primary is a closed panel plan and secondary is not, secondary pays as primary when member uses a noncontracted provider (except emergency services or authorized referrals).
Minimum inpatient stay requirements following mastectomy or lymph node dissection under Texas statutory notice.
Minimum inpatient stay: 48 hours following a mastectomy and 24 hours following a lymph node dissection for treatment of breast cancer unless member and attending physician agree a shorter stay is appropriate.
Prohibitions: Issuer may not deny or fail to renew eligibility solely to avoid providing minimum inpatient hours; may not offer payments or incentives to forego minimum stays nor penalize physicians for requiring minimum hours.
inv-31: Mandated coverages and notices
Mandated coverages and required notices (Texas and federal statutes) included in this Policy excerpt.
Minimum inpatient care after mastectomy/lymph node dissection as specified (48/24 hours) and rights regarding shorter stays if agreed by member and attending physician.
Coverage for reconstructive surgery after mastectomy including all stages of reconstruction, symmetry surgery of the other breast, prostheses and treatment of physical complications (including lymphedema) with cost-sharing aligned to similar inpatient/medical-surgical expenses.
Screening coverage mandates: prostate (annual exam and PSA for males >=50 or >=40 with risk), colorectal (screening for members >=45), ovarian and cervical cancer (annual exams and CA-125, Pap/HPV testing for women >=18).
Acquired brain injury mandated coverage: specified cognitive, neurobehavioral, testing, post-acute transition and community reintegration services are included when medically necessary.
COVID-19: Issuer will not require documentation of COVID-19 vaccination or post-infection recovery as a condition of coverage or benefits.
inv-32: Prescription drug coverage criteria
Prescription drug coverage criteria including formulary requirements, preauthorization, step therapy, specialty pharmacy dispensing, refill timing, and formulary governance.
Covered Prescription Drugs must be prescribed by a licensed Participating Health Professional, be FDA-approved for at least one indication, and be recognized for treatment of the prescribed indication by standard compendia or peer-reviewed medical literature.
Formulary: coverage provided in accordance with an evidence-based Formulary maintained by the Pharmacy & Therapeutics Committee; drugs placed on Formulary must have sufficient clinical evidence and committee review; copayments vary by tier.
Preauthorization/Authorization Requirements: certain medications subject to quantity limits, step therapy, and preauthorization; preauthorization may be required for Specialty Drugs and for non-specialty outpatient drugs meeting cost thresholds; exceptions exist (e.g., stage-four metastatic cancer drugs and certain serious mental illness rules).
Specialty pharmacy dispensing requirement: most Specialty Drugs must be dispensed from participating specialty pharmacies and failure to obtain from such pharmacies may result in denial of coverage.
Coding, Code Tables, and Key Coverage Metrics
None present in this portionmixed
No codes listed
Durable Medical Equipment (DME)mixed
Durable Medical Equipment (DME) definition; equipment that can withstand repeated use, primarily used to serve a medical purpose, not useful absent illness or injury, appropriate for home use; all requirements must be met before item considered DME.
Orthotic Devices: orthopedic or corrective shoes; shoe inserts; arch supports; orthotic inserts and other supportive devices including ankle braces required for recovery after surgery; coverage limited to most appropriate model as determined by Participating Provider.
Prosthetic Devices: artificial arms, legs, hands, feet, eyes; breast prostheses and surgical brassieres after mastectomy; initial device, fitting services, replacements not due to misuse or loss, and normal repairs; may require Preauthorization.
Hearing Aids and Cochlear Implants: fitting and dispensing services, ear molds, habilitation/rehabilitation, cochlear implant external speech processor and controller with component replacements every 3 years; one hearing aid per ear every 3 years for Members through age 18.
Prescription Drug / Infusion reviewmixed
Prescription Drugs and Intravenous Infusions: determinations will be made on medical necessity.
Covered Prescription Drugs: drugs dispensed following a Prescription Order from a licensed Participating Health Professional and meeting FDA approval and recognized indications; benefits available if FDA-approved for at least one indication and recognized by compendia or peer-reviewed literature.
Drug / Infusion determinationsmixed
Medical necessity determinations apply to prescription drugs and intravenous infusions.
Outpatient Specialty Drugs: designated on Formulary as Specialty Drugs and covered under outpatient specialty provision subject to specialty drug rules, copays, and Preauthorization.
Non-Specialty Drugs administered in outpatient settings may require prior approval if single-dose >= $450 or 12-month refill total >= $1,000; pharmacy-dispensed outpatient non-specialty drugs administered in office require prior Medical Director approval.
Preventive and Screening Services (age-specified)mixedCovered
Immunizations: age-appropriate immunizations (diphtheria, Hib, hepatitis B, measles, mumps, pertussis, polio, rotavirus, rubella, tetanus, varicella, and other immunizations required by law). No Copayments, Coinsurance, or Deductibles for immunization agents when delivered by Participating Provider.
Prostate Cancer Screening: annual diagnostic physical exam and PSA test for males age >=50 asymptomatic or >=40 with family history or risk factor.
Colorectal Cancer Screening: diagnostic, medically recognized screening for Members age >=45 at normal risk including USPSTF A/B tests, initial colonoscopy and follow-up colonoscopy if initial abnormal.
Mammography Screening: annual screening mammography for female Members age >=35; includes Low-Dose Mammography, Digital Mammography and Breast Tomosynthesis.
Cervical / HPV Testing: annual medically recognized diagnostic exam for women age >=18 including Pap smear (conventional or liquid-based) and FDA-approved HPV tests alone or in combination.
Ovarian Cancer Screening: CA-125 blood test and any FDA-approved ovarian cancer detection tests once every 12 months for women age >=18.
Preventive cancer screening groupsmixedCovered
Colorectal screening: Members age >=45 at normal risk; includes USPSTF A/B services and follow-up colonoscopy if initial abnormal.
Mammography screening: annual for females age >=35 using low-dose, digital, or tomosynthesis; diagnostic imaging covered comparably.
Cervical and HPV testing: annual diagnostic exam for women age >=18 including Pap smear and FDA-approved HPV tests.
Ovarian CA-125 testing: once every 12 months for women age >=18.
Durable Medical Equipment / Prosthetics / Hearing DevicesmixedCovered
Orthotic Devices: orthopedic/corrective shoes, shoe inserts, arch supports, orthotic inserts, ankle braces after surgery; initial device, fitting, replacement (not due to misuse or loss), professional services; limited to most appropriate model.
Prosthetic Devices: artificial limbs, eyes, breast prostheses and surgical brassieres after mastectomy; initial device, fitting, replacement, normal repairs; may require Preauthorization; limited to most appropriate model.
Hearing Aids and Cochlear Implants: fitting/dispensing services, ear molds, habilitation/rehabilitation; cochlear implant external speech processor/controller with replacements every 3 years; one hearing aid per ear every 3 years for Members through age 18; Plan not required to pay more than Plan benefit.
Biomarker Testing CriteriamixedCovered
Biomarker Testing: covered for diagnosis, treatment, management, or ongoing monitoring to guide treatment when supported by FDA labeled indications, FDA drug indications, CMS NCD/LCD, nationally recognized clinical practice guidelines, or consensus statements.
Prescription Drug ExclusionsmixedNot Covered
Over-the-counter drugs (except insulin) are excluded.
Items not specified as covered drugs (therapeutic devices, appliances, machines) are excluded except disposable insulin syringes for insulin-dependent Members.
Experimental or Investigational drugs and drugs not FDA-approved are excluded.
Drugs used for cosmetic purposes, treatments not covered by Agreement, drugs for infertility, vitamins not requiring a prescription, biological products, and any prescription dispensed more than one year after Physician's order are excluded.
Drugs given/administered while at a Hospital, Skilled Nursing Facility, or other Facility are excluded from outpatient pharmacy benefit.
Prescription drug coding guidancemixedCovered
Coverage limited to FDA-approved pharmaceutical products prescribed or ordered by Participating or Non-Participating Providers for use in humans for FDA-approved uses.
Specialty Drugs: outpatient specialty drugs designated on the Formulary covered under outpatient specialty provision subject to specialty drug rules; most specialty drugs must be dispensed from Participating Specialty Pharmacies.
Non-Specialty Drugs dispensed and administered in office or outpatient settings covered when meeting prior approval conditions; pharmacy-dispensed outpatient drugs administered in office require prior Medical Director approval.
Required claim documentationmixed
Itemized receipts must include name and address where services were received, date service provided, amount paid, and diagnosis. Claims must be received within one year of service; 90-day filing recommended with exceptions when not reasonably possible.
COB Definitionsmixed
'Plan' definition: includes group, blanket, franchise accident and health policies; individual and group HMO evidences; individual and group PPO plans; and other listed arrangements. Separate contracts used to provide coordinated coverage for group members are considered parts of same plan with no COB among them.
Allowed amount / allowable expense definitions: allowed amount is billed charge carrier determines covered for nonpreferred providers and includes carrier payment plus member cost-share; rules on allowable expense when multiple plans and negotiated fees described.
Order of Benefit Determination rules: primary plan pays first per its terms; tie-breaker and birthday, active/retired, COBRA/continuation, and length of coverage rules apply as described.
Order of Benefit Determination rulesmixed
No codes listed
Acquired brain injury services (no CPT/ICD codes provided in excerpt)mixedCovered
Covered services include cognitive rehabilitation therapy; cognitive communication therapy; neurocognitive therapy and rehabilitation; neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing and treatment; neurofeedback therapy and remediation; post-acute transition services and community reintegration services (including outpatient day treatment); reasonable expenses related to periodic reevaluation for individuals responsive to treatment after being previously unresponsive.
Not applicablemixed
No specific procedure or diagnosis codes listed in this section; prescription drug coverage limited to drugs dispensed following a Prescription Order and meeting FDA/state dispensing laws and Policy requirements.
Age of Ineligibility — key metric
Age of Ineligibility26
Definition contextAge at which dependents no longer eligible for coverage under this Policy
Applies toEligible Dependents as defined in Policy
Specialty Drug cost threshold — key metric
Preauthorization, Documentation, Billing, and Provider Obligations
Prior Authorization
Utilization Review and Preauthorization processes (TOC references)
The Plan maintains a Utilization Review program to evaluate inpatient and outpatient Hospital and Ambulatory Surgical Center admissions and specified non‑emergency outpatient surgeries, diagnostic procedures, and other services. Utilization Review activities include preauthorization review (prospective), admission review (pre‑ or post‑emergency admission), continued stay review (during a Hospital stay), and retrospective review (after services are performed). Certain benefits require Preauthorization to be covered; a complete list is available at BSWHealthPlan.com. Failure to obtain required Preauthorization for non‑Emergency Care will result in a penalty of the lesser of $500 or a 50% reduction in benefits.
Utilization Review includes Preauthorization, Admission Review, Continued Stay Review, and Retrospective Review.
Preauthorization is a prospective form of Utilization Review conducted by the Issuer or its Utilization Review agent.
A list of benefits requiring Preauthorization is published at BSWHealthPlan.com.
Note
Preauthorization definition
Defined Terms
Acquired Brain Injury definition
Acquired Brain Injury — definitionA neurological insult to the brain occurring after birth resulting in impairment of physical, sensory, cognitive, or psychosocial functioning.
Exclusions to termNot hereditary, congenital, or degenerative in origin per definition
Use in coverage determinationsTerm used to identify covered services such as cognitive rehabilitation, neurocognitive therapy, and community reintegration services
Amino Acid-Based Elemental Formulas (definition)
Amino Acid‑Based Elemental Formulas — definitionComplete nutrition formulas made from single nonallergenic amino acids for Members with immune responses to whole‑food proteins
Specialty Drug: a prescription drug requiring specialized handling/distribution, complex benefit review, close clinical monitoring, FDA- or guideline-mandated education, or with cost > $1,000 per prescription.
Independent Review / Experimental or Investigational: treatments considered Experimental or Investigational are defined by Medical Director review using peer-reviewed literature, IRB documents, FDA communications, and medical records; such determinations are adverse determinations subject to appeal and independent review processes.
For non-emergency treatment by a Non-Participating Provider at a Participating Facility, Member will not be liable for amounts greater than applicable Copayment and Deductible that would have applied had services been furnished by a Participating Provider; Issuer will pay provider within 30 days of a clean claim.
Continuity of Care protections: Members receiving ongoing care (serious/complex condition, institutional/inpatient care, nonelective surgery including post-op care, pregnancy beyond 24th week, terminal illness) qualify as continuing care patients and may elect transitional care when a Participating Provider contract terminates; transitional coverage continues up to 90 days after notice (9 months for terminal illness) and terminated provider agrees to accept Issuer payment as payment in full.
Utilization Review program evaluates inpatient/outpatient admissions, specified surgeries, diagnostic procedures, and other services and includes Preauthorization, Admission Review, Continued Stay Review, and Retrospective Review; failure to obtain Preauthorization may result in penalties or reduction/denial of benefits.
Preexisting condition limitation: benefits for treatment of a preexisting condition are excluded for 12 months from Member's Effective Date subject to credit for prior Creditable Coverage and exceptions for Covered Dependents age 18 and under.
Ambulance Transport: Ground/Sea/Air ambulance covered when Medically Necessary; air transport not covered if ground is appropriate and more economical; sea/air non-emergency interfacility transport requires Preauthorization by Medical Director.
Preventive Care and Immunizations: USPSTF A/B services, CDC-recommended immunizations, and HRSA-supported preventive services for infants/children/adolescents and women are covered with no Copayment, Coinsurance, or Deductible when delivered by a Participating Provider; examples include annual physicals, well-child visits, immunizations, bone density, cancer screenings, and newborn hearing screening through age 2 follow-up.
Prostate Cancer Screening: annual diagnostic exam and PSA test covered for males age >=50 asymptomatic or >=40 with family history/risk factor.
Colorectal Cancer Screening: diagnostic, medically recognized screening covered for Members age >=45 at normal risk including USPSTF A/B tests; initial and follow-up colonoscopy covered if initial is abnormal.
Ovarian cancer screening: CA-125 blood test and any FDA-approved ovarian cancer detection tests once every 12 months for women >=18.
Hospital services: medically necessary inpatient services at Participating Hospitals covered; if admitted to Non-Participating Hospital by Participating Provider, covered if approved; Member must notify Issuer within 48 hours of non-participating admission where reasonably possible.
Rehabilitative/Habilitative therapy: outpatient physical, speech, hearing, occupational therapy covered when ordered by Participating Provider, expected to meet goals, provided by licensed professionals, and Member is progressing toward goals; maintenance goals allowed for physical disability.
Home Health Care: preauthorized medically necessary home health (skilled nursing, therapies, home health aide, equipment/supplies) covered under plan of care established, approved and reviewed every two months and certified by attending Physician.
Home Infusion Therapy: medically necessary home infusion approved by Issuer for high-technology services (line care, chemotherapy, pain management, anti-infectives) covered including pharmacy services and supplies; specialty drugs via infusion covered under Specialty Drug benefit; cost-sharing per Schedule applies.
Hospice: covered when provided by Participating Hospice licensed in Texas, preauthorized, and attending Provider certifies life expectancy of six months or less; includes pain relief, symptom management and supportive benefits
Family Planning: medically necessary family planning services covered (counseling, diagnostic infertility procedures excluding infertility treatment, vasectomy, tubal ligation, laparoscopies); FDA-approved contraceptives covered with initial 3-month supply and subsequent 12-month supply allowance; one 12-month supply per plan year.
Fertility preservation: coverage for fertility preservation services for Members receiving medically necessary cancer treatment that may impair fertility as established by ASCO/ASRM guidance.
Durable Medical Equipment (DME), Orthotics, Prosthetics: medically necessary DME, orthotic and prosthetic devices covered as determined by Medical Director with treating Physician; coverage conditions include length of time, equipment, supplier, basis of coverage; benefits limited to Schedule maximums.
Consumable supplies: covered only if required to use with covered DME/orthotic/prosthetic; disposable and single-member use; repair/maintenance for abuse is Member responsibility; consumable benefits applied to device maximum.
Orthotic devices: coverage for initial device, fitting, and replacement (unless due to misuse/loss) for items including orthopedic shoes, inserts, arch supports, ankle braces required for recovery after surgery; limited to most appropriate model.
Prosthetic devices: may require Preauthorization; covered when Medically Necessary to replace body parts after injury/illness including artificial limbs, eyes, breast prostheses and surgical brassieres post-mastectomy; includes initial device, fitting, replacement (not due to misuse/loss) and normal repairs; limited to most appropriate model.
Coverage level determination order: inpatient-administered drugs, outpatient Specialty Drugs, outpatient non-specialty drugs administered in office/outpatient setting, then outpatient non-specialty drugs dispensed at pharmacy (if Prescription Drug Rider attached). All Prescription Drug coverage subject to Exclusions and Limitations.
Cardiovascular screening: one qualifying noninvasive atherosclerosis screening test (CT coronary artery calcium or carotid ultrasonography) covered every 5 years for eligible members meeting age and risk criteria and when performed by certified facility/provider; benefit maximum $200 per member every 5 years.
Telehealth: telehealth and telemedicine services covered subject to same terms and conditions as in-person benefits; in-person consultation not required.
Biomarker testing: covered when supported by FDA labeling, FDA drug indication, CMS NCD/LCD, nationally recognized clinical practice guidelines, or consensus statements for diagnosis, treatment, management, or monitoring to guide treatment.
Cosmetic or reconstructive procedures to improve/modify appearance are excluded except specified exceptions for post-mastectomy and pediatric craniofacial reconstruction when medically necessary and approved by Medical Director.
Court-ordered care, treatments provided solely due to court/administrative order, are excluded.
Treatment required as result of voluntary participation in commission of a felony resulting in conviction is excluded.
Custodial care (rest, domiciliary, assistance with activities of daily living) is excluded.
All dental care is excluded unless Schedule of Benefits or dental rider provides otherwise.
In major disaster/epidemic care reimbursed at in-network level to extent available but Issuer and providers have no liability for delays or inability to reimburse due to limited facilities/personnel.
Elective treatments or surgery and complications are excluded.
Storage of bodily materials: long-term storage (>6 months) of blood/blood products excluded; storage of semen, ova, bone marrow, stem cells, DNA or other bodily materials excluded unless approved by Medical Director.
Transplants: organ and bone marrow transplants and associated donor/procurement costs are excluded except where specifically listed as covered.
Weight reduction services (including surgical procedures) and work-related/occupational injury treatments are excluded.
Refill and maintenance rules: refills not covered until Member reasonably due; maintenance drugs may qualify for medication synchronization; specific refill timing rules for eye drops and emergency refills of diabetes supplies apply; insulin and supplies limits specified per law.
Formulary change governance: if a drug appears on Formulary at Plan Year start, it remains available at contracted benefit level until Plan Year end; committee meets at least quarterly; minimum availability period and member/commissioner notice requirements apply for formulary modifications.
Specialty Drug cost threshold$1,000 per prescription
Definition linkageDrugs with any dosage form having total cost > $1,000 per prescription may meet Specialty Drug criteria
Additional criteriaAlso includes drugs requiring specialized handling, complex management, or FDA/guideline-mandated education
Specialty drug cost threshold — alternate phrasing
Alternate phrasing (policy text)Any prescription drug containing any dosage form with a total cost greater than $1,000 per prescription may be classified as a Specialty Drug.
ContextAppears within the Specialty Drug definition and influences benefit assignment
ImplicationTriggers Specialty Drug benefit rules (dispensing, copays, preauthorization) when threshold met
Maximum Out-of-Pocket — key metric
Maximum Out-of-Pocket (MOOP) basisAs shown on the Schedule of Benefits; In‑Network MOOP example: $4,000 member / $8,000 family
Exclusions from MOOPRequired payments under Riders and Level 4 specialty drug copays are not counted toward MOOP
Effect after MOOP reachedIn‑Network covered benefits paid at 100% with no Copayments or Coinsurance
Prostate (PSA) screening agesAnnual diagnostic exam and PSA: age ≥50 asymptomatic; age ≥40 with family history or risk factor
Colorectal screening start ageMembers age 45 and older (average risk) — initial and follow-up colonoscopy covered
Ovarian CA-125 screening frequencyOnce every 12 months for women age 18 and older (CA-125 blood test and FDA-approved ovarian tests)
Non-specialty outpatient drug single-dose preauth threshold
Single-dose preauthorization threshold (non-specialty outpatient drug)$450 for a single dose administered in an outpatient setting
ScopeApplies to outpatient prescription drugs dispensed and administered in a Participating Provider office or outpatient setting
ConsequenceMay require Preauthorization by the Issuer if single-dose cost ≥ $450
Non-specialty outpatient drug 12-month refill preauth threshold
12‑month refill preauthorization threshold (non-specialty outpatient)$1,000 total cost over 12 months
ScopeRefillable prescriptions whose total cost during a 12‑month period could equal or exceed $1,000 may require Preauthorization
Applies toOutpatient non‑specialty drugs dispensed and administered in outpatient settings
Cardiovascular screening interval
Cardiovascular screening intervalOne test every 5 years when criteria are met
Eligible populationMales >45 and <76; females >55 and <76 with diabetes or intermediate/higher Framingham risk score
Covered testsCT coronary artery calcium or carotid ultrasonography when preauthorized and performed by certified facility/provider
Preexisting condition waiting period
Preexisting condition waiting period12 months from Member's Effective Date
ExceptionsExceptions for prior creditable coverage and for dependents age 18 and under per policy provisions
Applies toBenefits for treatment of a preexisting condition as defined in Policy
Long-term storage exclusion threshold
Long-term storage exclusion thresholdStorage longer than 6 months is excluded
ScopeApplies to blood and blood products; storage of semen, ova, bone marrow, stem cells, DNA, or other bodily materials excluded unless approved by Medical Director
Exception pathMay be approved by Our Medical Director on a case-by-case basis
Claims receipt after service (timely filing maximum)
Timely filing maximum (claims receipt after service)Issuer has no obligation if proof of claim not received within one (1) year of the date services were provided
Standard submission guidanceWritten proof and Claim should include itemized receipts with provider name/address, date of service, amount paid, and diagnosis
90‑day rule caveatFailure to file within 90 days does not invalidate claim if not reasonably possible to file sooner and filed as soon as reasonably possible
Allowed amount definition
Allowed amount definitionThe Allowed Amount is the amount of a billed charge that the carrier determines to be covered for services provided by a nonpreferred provider; it includes both the carrier's payment and any applicable Deductible, Copayment, or Coinsurance for which the insured is responsible.
ContextUsed in Coordination of Benefits and reimbursement calculations
ImplicationDetermines carrier payment and member cost‑share components for nonpreferred providers
Minimum inpatient hours after mastectomy/lymph node dissection
Shorter stay allowanceMinimum hours not required if Member and attending physician determine a shorter inpatient stay is appropriate
ProtectionsInsurer may not deny/terminate or incentivize shorter stays to avoid providing minimum hours
In-Network Calendar Year Deductible example
In‑Network Calendar Year Deductible example$1,000 member / $2,000 family (example shown)
Deductible effectDeductible applies to Maximum Out‑of‑Pocket; family deductible is cumulative
Out‑of‑Network exampleOut‑of‑Network deductible example shown as $2,000 / $4,000 in related table
In-Network Maximum Out-of-Pocket example
In‑Network Maximum Out‑of‑Pocket example$4,000 member / $8,000 family
Post‑MOOP coverageIn‑Network covered benefits paid at 100% with no Copayments or Coinsurance once MOOP reached
Exclusions from MOOPCertain Rider payments and Level 4 specialty drug copays do not count toward MOOP
Outpatient Specialty Drug Deductible (In-Network)
Outpatient Specialty Drug Deductible (In‑Network)$250 deductible applies prior to coverage for covered outpatient In‑Network specialty drugs
Benefit tieringSpecialty drugs have tiered copays after deductible (e.g., 10%, 20%, etc.) per formulary tier
Administration settingOutpatient specialty drugs are covered under the outpatient Specialty Drug benefit regardless of administration site
Cardiovascular screening benefit maximum
Cardiovascular screening benefit maximum$200 per member every 5 years
Copayment example20% after deductible for CT or ultrasonography (In‑Network) with $200 maximum benefit per 5 years
Applies when criteria metBenefit available only when member meets age/risk criteria and test is preauthorized/performed by certified provider
Preauthorization means a prospective Utilization Review of proposed health care to be provided to a Member. Providers and Members must comply with Preauthorization requirements for services so designated by the Plan.
Prior Authorization
Preauthorization process and contact requirements
To satisfy Preauthorization requirements, a Member or Participating Provider should contact the authorization phone number on the Member ID Card during business hours at least three (3) calendar days prior to admission or the scheduled date of a proposed benefit that requires Preauthorization. Participating Providers may obtain Preauthorization on behalf of Members, but Members remain responsible for ensuring Preauthorization is secured. For Emergency admissions or procedures, the Plan must be notified within forty‑eight (48) hours of the admission/procedure or as soon as reasonably possible. If the Plan questions Medical Necessity, the provider will be given a reasonable opportunity to discuss the case with the Medical Director prior to an Adverse Determination. Written notice of an Adverse Determination will be provided within three (3) days and will include reason(s), clinical basis, source of screening criteria, and appeal instructions. Members with Life‑Threatening Conditions (including emergencies, continued hospitalization, or certain drug/infusion situations) have the right to an immediate review by an Independent Review Organization without first exhausting internal appeals.
Authorization phone available on Member ID Card — business days 6:00 AM–6:00 PM CT; weekends/holidays 9:00 AM–12:00 PM CT.
Participating Providers may be exempt from Preauthorization for certain services if they meet exemption criteria.
Emergency notification required within 48 hours; Plan may consider inability to notify due to severity of condition.
Denial Risk
Utilization Review scope and consequences of failure to preauthorize
Utilization Review applies to admissions, specified outpatient surgeries and procedures, and other services identified by the Plan. If Preauthorization is not performed, the Plan will determine Medical Necessity at the time of admission. Failure to Preauthorize benefits that are later found not Medically Necessary may result in reduction or denial of benefits and additional Member charges that do not count toward Deductible or Maximum Out‑of‑Pocket.
Scope includes inpatient and outpatient Hospital and Ambulatory Surgical Center admissions and specified non‑emergency outpatient surgeries, diagnostic procedures, and other services.
Consequences: possible benefit reduction/denial and Member liability if service not Preauthorized and not Medically Necessary.
Note
Admission and Continued Stay Review timelines
Admission review will be performed when Preauthorization review is not completed; the Plan will assess Medical Necessity at the time of admission. Continued stay review determines whether an ongoing Hospital or Skilled Nursing Facility stay is Medically Necessary. The Plan will provide notice of continued stay determinations within twenty‑four (24) hours via telephone or electronic transmission to the provider of record and follow with written notice to the Member or provider of record within three (3) working days. For Post‑Stabilization care following Emergency Care related to a Life‑Threatening Condition, the Plan will notify the treating provider within the time appropriate to the circumstances but in no case exceed one (1) hour after the request for approval is made.
Admission Review: determination of Medical Necessity at time of admission if Preauthorization not obtained.
Continued Stay Review: notice to provider within 24 hours; written notice within 3 working days to Member/provider.
Post‑Stabilization approvals/denials tied to clinical urgency — notification within 1 hour for requests related to Life‑Threatening Conditions.
Prior Authorization
Hearing Aid / Cochlear Implant Preauthorization
Hearing aids and cochlear implants may require Preauthorization. The Plan covers fitting/dispensing, ear molds, habilitation/rehabilitation related to these devices, and an external speech processor/controller (with component replacements every three years for cochlear implants). Limitations include one hearing aid per ear every three years for Members through age 18, required prescribing qualifications, and possible Plan coverage limits to the least expensive appropriate device. Coverage is subject to general Durable Medical Equipment provisions (Deductibles, Copayments, Coinsurance, and Preauthorization).
One hearing aid per ear every three years for Members ≤ age 18.
Hearing aid prescription must be written by an otolaryngologist/otologist or a legally qualified audiologist (or ASHA CCC in absence of licensing) at the direction of an otolaryngologist/otologist.
Cochlear implant: one implant per ear with internal replacement as medically/audio‑logically necessary; external processor component replacements every 3 years.
Billing Rule
Claim Submission by Provider/Member — timeframes and required proof
If a Member pays a provider or Facility and seeks reimbursement, submit written proof and a Claim for payment to the Issuer. Written proof and Claim for payment must be acceptable to the Plan and received within ninety (90) days of the date benefits were received, unless it was not reasonably possible—in which case claims must be filed as soon as reasonably possible. Itemized receipts should include provider name/address, date of service, amount paid, and diagnosis. Claims should be mailed to Baylor Scott & White Insurance Company, Attn: Claim Department, 1206 W. Campus Drive, Temple, TX 76502. The Issuer will have no obligation if proof/claim is not received within one (1) year of the service date.
Submit itemized receipts with name/address of service location, date of service, amount paid, and diagnosis.
Standard filing timeframe: within 90 days; absolute cutoff: within one (1) year of service date unless reasonably impossible to file within 90 days.
Note
Claim Processing Timelines — acknowledgement and decision windows
The Issuer will acknowledge receipt of a Claim in writing not later than the fifteenth (15th) day after receipt, begin any investigation, and request any necessary information. After all requested items are received, the Issuer will notify acceptance or rejection within fifteen (15) business days, or if additional time is needed, will do so no later than the forty‑fifth (45th) day after You were notified of the need for more time. Accepted claims will be paid no later than the fifth (5th) business day after notification of acceptance.
Acknowledgement: within 15 days of receipt of Claim.
Decision after receipt of all information: within 15 business days; if more time needed, final decision no later than 45 days after notice of extension.
Payment timeline: within 5 business days after acceptance.
Billing Rule
Timely Filing Limits — one year ultimate cutoff
Failure to submit written proof and a Claim within the Plan's 90‑day guideline will not automatically invalidate reimbursement if it was not reasonably possible to file in time and proof was filed as soon as reasonably possible. However, in no event will the Issuer have an obligation if such proof and Claim for payment are not received within one (1) year of the date the services were provided.
Normal filing window: 90 days from date services were received.
Exception allowed if it was not reasonably possible to file within 90 days, but final absolute limit: 1 year.
Billing Rule
Secondary Plan Payment Adjustment
When this Plan is secondary, the Plan may reduce its benefits so total payments from all plans do not exceed the total allowable expense. The secondary plan will calculate what it would have paid absent other coverage, apply that amount to any unpaid allowable expense, and then reduce its payment so combined payments equal 100% of the allowable expense. The secondary plan must credit to its Deductible any amounts it would have credited in the absence of other coverage.
Secondary payment adjustment ensures combined payments from primary and secondary plans do not exceed 100% of allowable expense.
Secondary plan credits amounts toward its Deductible as if it had been primary.
Step Therapy
Non‑formulary and appeals process
To request coverage for a non‑Formulary medication, the Member or prescribing Participating Provider/Health Professional must submit a Preauthorization request to the Utilization Review Agent. If an Adverse Determination is issued for a pharmacy benefit drug, the Member has the right to appeal; details and appeal submission processes are available at BSWHealthPlan.com. For step therapy, a provider may request an exception; if a step therapy exception is not denied within seventy‑two (72) hours it will be considered granted (or within twenty‑four (24) hours if failure to decide would result in death or serious harm).
Non‑Formulary coverage requires Preauthorization submission to the Utilization Review Agent.
Adverse Determination of pharmacy benefit drugs may be appealed; appeal procedures are posted at BSWHealthPlan.com.
Step therapy exception: deemed granted if not denied within 72 hours; expedited 24‑hour resolution if potential for death or serious harm.
Used for diagnoses such as IgE/non‑IgE mediated multiple food protein allergies, severe FPIES, eosinophilic disorders with biopsy evidence, and impaired absorption disorders (subject to schedule maximums)
Coverage noteAdministration services covered; subject to Calendar Year maximum and applicable cost sharing
Biomarker Testing (definition)
Biomarker Testing — definitionAnalysis of tissue, blood, or other biospecimens for presence of biomarkers, including single‑analyte tests, multiplex panels, and next generation sequencing
Coverage criteriaCovered when supported by FDA labeling, FDA drug indication, CMS NCD/LCD, nationally recognized guidelines, or consensus statements
PurposeUsed for diagnosis, treatment selection, management, or monitoring to guide treatment
Coinsurance (definition)
Coinsurance — definitionThe percentage of Covered Expenses the member is responsible for paying after applicable Deductibles are satisfied; excludes charges for non‑covered services or excess charges
Calculation noteCoinsurance does not include charges not covered by the Policy or amounts above Covered Expenses
Member responsibilityMember pays coinsurance portion for covered services after deductible is met
Amino Acid‑Based Elemental Formulas (alt phrasing)Complete nutrition formulas designed for Members with immune responses to whole‑food allergens, made from individual nonallergenic amino acids and easily absorbed/digested.
Coverage conditionsMedically necessary as ordered by a Participating Provider; subject to Schedule maximums and cost sharing
AdministrationAdministration services for formulas may be covered when medically necessary
Clinician-Administered Drug (definition)
Clinician‑Administered Drug — definitionAn outpatient prescription drug (other than a vaccine) that cannot reasonably be self‑administered and is typically administered by a physician or authorized provider in a physician's office
Examples/contextIncludes drugs requiring administration by clinician in office setting; distinct from pharmacy‑dispensed drugs
Coverage implicationMay be covered under medical benefit when medically necessary; does not require use of Participating Pharmacy
Experimental or Investigational (definition)
Experimental or Investigational — definitionTreatment not proven successful in improving health as determined by the Medical Director using peer‑reviewed literature, IRB documents, FDA/HHS communications, informed consent, and medical records
Evidence consideredWell‑designed controlled trials, informed consent materials, IRB documents, FDA communications, and member medical records
Coverage effectConsidered an Adverse Determination if treatment deemed Experimental/Investigational and may be excluded
Medically Necessary (definition)
Medically Necessary — definitionServices that are in accordance with accepted standards of medical practice, clinically appropriate in type/frequency/extent/site/duration, and not primarily for convenience; determination subject to Participating Provider opinion and Medical Director review
Decision authorityParticipating or Non‑Participating Provider opinion subject to review and determination by Our Medical Director
Coverage implicationOnly services deemed Medically Necessary are covered under the Plan
Routine Patient Care Costs (clinical trials) definition
Routine Patient Care Costs (clinical trials) — definitionCosts of medically necessary care provided under the Plan irrespective of clinical trial participation; excludes investigational products, trial management costs, non‑covered services, and services inconsistent with standards of care
Coverage limitsPlan will not reimburse Research Institute for routine care unless institute/providers accept Plan rates; member cost‑sharing applies
ExclusionsServices part of the trial subject matter and customarily paid by Research Institute are excluded
Specialty Drug (definition)
Specialty Drug — definitionAny prescription drug requiring specialized handling/distribution, complex benefit review, close clinical monitoring, FDA/guideline‑mandated education, or with total cost > $1,000 per prescription
Examples of criteriaSpecialized procurement, complex medical management, required education, or high total cost per prescription
Benefit effectSubject to Specialty Drug benefit rules, dispensing through specialty pharmacies, and specific copay/deductible treatment
Telemedicine Medical Services (definition)
Telemedicine Medical Services — definitionHealth care services delivered by a Physician licensed in this state to a patient at a different physical location using telecommunication or information technology
Coverage parityTelemedicine services are subject to same terms and conditions as in‑person benefits
In‑person not requiredAn in‑person consultation is not required as a condition of coverage
Urgent Care (definition)
Urgent Care — definitionPrompt treatment for a medical condition where brief delay will not endanger life or permanent health; includes minor sprains, fractures, pain, heat exhaustion
SettingProvided at licensed Urgent Care Center Facilities contracted with the Issuer
Distinction from EmergencyNot life‑threatening conditions; emergencies handled under Emergency Care rules
Participating Provider (definition)
Participating Provider — definitionProviders who contract with the Issuer to deliver covered benefits; independent contractors determining treatment methods
RelationshipParticipating Providers are not agents of the Issuer; Issuer is not agent of providers
Member expectationMembers may not be entitled to specific provider classes beyond Agreement terms
Medical Necessity (definition — alternate)
Medical Necessity (alternate) — definitionBenefits available must meet the Medical Necessity definition provided in the Definitions section; determinations made per those standards
Operational noteMedical Necessity determinations guide coverage and Utilization Review outcomes
Appeal linkAdverse Determinations based on Medical Necessity can be appealed per internal and independent review processes
Adverse Determination / Final Internal Adverse Determination definitions
Adverse Determination / Final Internal Adverse Determination — definitionsAdverse Determination: issuer or utilization review organization decision that requested care is not Medically Necessary or is Experimental/Investigational. Final Internal Adverse Determination: adverse determination upheld after internal appeal.
Appeal pathMember may seek Independent Review Organization review under Chapter 4202 if internal appeal denied
Issuer obligationsIssuer must provide records to IRO within 3 business days and comply with IRO determinations
Case Management definition
Case Management — definitionNurse‑led coordination program to aid Members with chronic or complex needs offering resources, education, and care navigation
Services providedAssistance accessing community resources, education on condition management, help navigating the healthcare system
ParticipationMembers with qualifying conditions may be contacted and offered participation in case management
Medically Necessary (duplicate reference)
Medically Necessary (duplicate) — definitionServices meeting accepted medical standards, clinically appropriate in type/frequency/extent/site/duration, not primarily for convenience; subject to Medical Director review
Role in coveragePrimary standard for determining covered services under the Plan
Review authorityMedical Director and Quality Assurance Committee may review determinations
Incontestability definition
Incontestability — definitionStatements on the Enrollment Application cannot be used to contest the policy after it has been in force for two years, except for fraud or intentional material misrepresentation on a signed application
Contest conditionsContest allowed only for fraud or intentional material misrepresentation and when signed Enrollment Application furnished to Subscriber
EffectProvides stability to coverage after two‑year period absent fraud
Qualified Individual (bone mass measurement) — definition
Qualified Individual (bone mass measurement) — definitionPostmenopausal women not on estrogen; individuals with vertebral abnormalities, primary hyperparathyroidism, history of fractures; those on long‑term glucocorticoids; or being monitored for osteoporosis drug therapy
UseEligible for medically accepted bone mass measurement screening
CoverageBenefits available for bone mass measurement when Qualified Individual criteria met
Coverage Level for Prescription Drug Benefits (definition)
Coverage Level for Prescription Drug Benefits — definitionPrescription drug coverage assigned in order: inpatient admin drugs; outpatient Specialty Drug; outpatient non‑specialty administered in office; outpatient non‑specialty dispensed at pharmacy if Rider attached
Policy noteAll prescription drug coverage subject to Exclusions and Limitations provision
Formulary governanceFormulary developed by Pharmacy & Therapeutics Committee using evidence‑based review
Breast Reconstruction (definition/mandate)
Breast Reconstruction — definition/mandateSurgical reconstruction of a breast and nipple‑areola complex incident to mastectomy, including reconstruction of the other breast for symmetry, prostheses, and treatment of complications (including lymphedema)
Coverage parityDeductibles and copayments same as other similar inpatient/medical‑surgical expenses
LimitOnce symmetry attained, subsequent cosmetic surgery excluded unless for functional problems
Routine Patient Care (definition duplicate)
Routine Patient Care (clinical trials) — definition (duplicate)Medically necessary routine care costs for trial participants excluding investigational products, trial management costs, and non‑covered services
Reimbursement caveatResearch Institute must accept Plan rates for reimbursement; non‑participating providers' routine care not covered
Member cost shareMember responsible for Deductible/Coinsurance/Copays per Schedule of Benefits
Biomarker Testing (definition — criteria support)
Biomarker Testing (definition — criteria support)Biomarker testing covered when supported by FDA labeling, FDA drug indication, CMS NCD/LCD, nationally recognized guidelines, or consensus statements
Intended useFor diagnosis, treatment selection, management, or ongoing monitoring to guide treatment
Evidence typesIncludes labeled FDA tests, CMS determinations, national guidelines, or consensus statements
Disaster or Epidemic (definition)
Disaster or Epidemic — definitionEvent in which care shall be reimbursed at In‑Network benefit level to extent available at Participating Providers; issuer/providers not liable for delays due to limited facilities/personnel
Reimbursement effectIn‑Network level reimbursement applies where participating resources are available
LimitationsNo liability for inability to reimburse at In‑Network level due to lack of facilities/personnel
Organ Transplant Geographic Exclusion (definition)
Organ Transplant Geographic Exclusion — definitionOrgan transplants and post‑transplant care excluded if performed in or organs procured from countries known to have participated in forced organ harvesting (e.g., China)
ScopeApplies to transplant operations and procured organs from excluded countries
Policy effectSuch transplants not covered under this Policy segment
Physical and Mental Exams (definition/exclusion)
Physical and Mental Exams — exclusion definitionPhysical, psychiatric, psychological, and other exams/reports for employment, licensing, insurance, educational, legal, research, and similar non‑medical purposes are excluded
ExamplesEmployment, licensing, insurance, educational, premarital, pre‑adoptive, judicial/administrative, and research purposes
Coverage implicationSuch exams and related reports are not covered benefits under the Policy
Long term storage (definition/exclusion)
Long term storage — definition/exclusionLong‑term storage (longer than 6 months) of blood and blood products is excluded; storage of semen, ova, bone marrow, stem cells, DNA, or other bodily materials excluded unless approved by Medical Director
Exception pathApproval may be granted by Our Medical Director in specific cases
Coverage effectStorage costs generally not reimbursable under Policy
Voluntary Binding Arbitration (definition)
Voluntary Binding Arbitration — definitionFinal dispute resolution option if complaint/appeal process exhausted and both parties agree; administered by AAA under Healthcare Payor Provider Arbitration Rules; governed by Texas law
Arbitrator requirementsSingle arbitrator with at least 15 years relevant industry experience; AAA selection process
Limitations on awardsArbitrator may not award punitive, incidental, consequential, or non‑contractual damages and must conform to Agreement terms
Subrogation and Assignment (definition)
Subrogation and Assignment — definitionPlan is subrogated to participant's recovery rights to the extent of benefits provided and is granted a lien on recovery proceeds; participant is considered to have assigned recovery rights upon receiving benefits
Sources includedThird‑party liability, uninsured/underinsured coverage, no‑fault, workers' compensation, indemnity agreements, and other sources of payment
Participant obligationsParticipant must notify Plan, cooperate, and obtain Plan consent before settlements; Plan may reduce future benefits if unreimbursed
Medicare Coordination (definition)
Medicare Coordination — definitionWhen Medicare is primary, Member must maintain Medicare Part B, pay premiums, and cooperate in coordination; Issuer pays difference between Allowed Expense and Medicare payment as applicable
Member obligationsMaintain Part B coverage and pay premiums; cooperate to maximize reimbursement from Medicare and Issuer
Effect on benefitsIssuer reduces or coordinates benefits consistent with Medicare payments and applicable law
Plan (definition)
Plan — definitionAny arrangement providing medical, dental, or vision benefits or coordinated coverage under separate contracts; lists included and excluded plan types
ExamplesGroup/individual health insurance, HMOs, preferred provider plans, Medicare (as permitted), and other specified arrangements
Not includedWorkers' compensation, disability income, fixed indemnity, certain long‑term care components, and specified exclusions
Allowable expense (definition)
Allowable expense — definitionA health care expense covered at least in part by any plan; examples of non‑allowable expenses include private room differential and amounts above highest reimbursement when multiple plans apply
Use in COBBasis for determining payments when coordinating benefits among multiple plans
ExamplesAmounts reduced due to member failure to comply with plan provisions are not allowable expenses
Allowed amount (definition)
Allowed amount — definitionThe amount of a billed charge that a carrier determines to be covered for services provided by a nonpreferred provider; includes carrier payment plus any applicable Deductible, Copayment, or Coinsurance
Role in claimsDetermines carrier payment and member cost‑share components for nonpreferred providers and COB calculations
Synonym contextOften used interchangeably with 'allowed charge' or 'allowable amount' in reimbursement rules
Closed panel plan; Custodial parent (definitions for COB)
Closed panel plan; Custodial parent — definitionsClosed panel plan: plan providing benefits primarily through contracted panel providers, excluding other providers except emergencies/referrals. Custodial parent: parent with court‑ordered designation or where child resides >50% of year.
COB relevanceDefinitions used in Order‑of‑Benefit Determination rules for dependent children and other COB scenarios
ApplicationAffects primary/secondary plan determination in coordination of benefits
Order of Benefit Determination (definition)
Order of Benefit Determination — definition summaryRules to determine which plan is primary or secondary including nondependent vs dependent, birthday rule for children, active vs retired employee, COBRA/state continuation, and longer/shorter length of coverage; equal sharing if unresolved
Tie‑breaker examplesBirthday rule for parents, active employee precedence, COBRA continuation treated secondary to active plan
EffectDetermines payment order and potential benefit reductions by secondary plan
Confidential Information / Records (definition/requirement)
Confidential Information / Records — definition/requirementOrganization administering COB must comply with federal/state confidentiality laws and may request Member facts necessary to apply COB rules; Issuer entitled to medical records to administer Agreement
Member obligationMember must provide information required by Issuer; records made available for inspection as needed
Data useInformation used to determine benefits payable under this Plan and other plans
Reconstructive surgery after mastectomy (definition/mandate)
Reconstructive surgery after mastectomy — mandate/definitionIncludes all stages of reconstruction of the breast on which mastectomy performed, surgery of the other breast for symmetry, prostheses, and treatment of physical complications (including lymphedema); coverage provided as required by WHCRA and Texas statute
Cost sharingDeductibles and copayments same as for other similar inpatient/medical‑surgical expenses
ProhibitionsIssuer may not deny/limit eligibility or offer incentives to forego reconstruction or shorter stays to avoid providing mandated benefits
Minimum inpatient stay (definition/mandate)
Minimum inpatient stay — mandate/definitionMinimum inpatient stay: 48 hours after mastectomy and 24 hours after lymph node dissection unless Member and attending physician agree to shorter stay
ProtectionsInsurer prohibited from denying/terminating coverage or incentivizing shorter stays to avoid compliance
ApplicationStatutory notice applies to members receiving mastectomy/lymph node dissection for breast cancer treatment
Covered Prescription Drugs (definition)
Covered Prescription Drugs — definitionDrugs dispensed following a Prescription Order from a licensed Participating Health Professional and meeting federal/state dispensing laws; must be prescribed/filled as specified to be Covered
Medical Director roleMay require substitution of a Prescription Drug for another based on Pharmacy & Therapeutics Committee recommendations to provide equal/better results at lower cost
Coverage conditionsDrugs must be FDA‑approved for at least one indication and recognized by compendia or peer‑reviewed literature for the indicated use
Formulary / Evidence Based Formulary (definition)
Formulary / Evidence Based Formulary — definitionAn evidence‑based list of Prescription Drugs developed and maintained by the Pharmacy and Therapeutics Committee selecting drugs based on safety, effectiveness, and cost
GovernanceCommittee meets at least quarterly to review scientific and economic evidence before Formulary placement
Formulary effectDrugs selected for Formulary determine coverage tiers, copays, and utilization management requirements