Blue Cross Blue Shield of Texas (BCBSTX) provides health care benefits and access to services to assist you in staying healthy. BCBSTX covers all medically essential treatments that Medicaid supports. Its offerings include visits to primary care physicians, specialists (with prior approval for out-of-network doctors), or other providers Routine physicals for children aged one to twenty years. Adults should have yearly physicals.
What Is Meant By Emergency?
A risky or catastrophic event, such as an accident, occurs unexpectedly or quickly and necessitates immediate action.
When it comes to health care, you have options. Your finger is wounded does not necessitate a trip to the emergency department (ER). Even if you go to the ER, your visit may not be covered in other situations. That implies you might wind up paying a portion of the full price.
Guidelines For Emergency Room:
1. When Should ER Be Used?
A person should visit if they are experiencing life-threatening symptoms, such as:
- Heart issues
- Breathing difficulties
- Significant bleeding
- Bone fractures
- Extreme discomfort
2. When Shouldn’t ER Be Used?
If a person is suffering from any injury or disease that is not life-threatening, they can use services other than the ER. Following are the kinds of health issues that do not require an emergency room.
- Symptoms of colds, sore throats, and the flu
- Ear or sinus discomfort
- Rashes
- Cuts that do not require stitches
- Constipation
- Bearable pain
3. Out-of-Network Coverage
In most circumstances, your care must be provided by a STAR in-network plan provider. If no one in the network can provide you with the care you require, your primary care physician (PCP) will receive authorization from us to refer you to a provider who is not in the network. You do not need our permission to seek emergency or urgent treatment. Similarly, you do not need our permission or to be referred by your primary care physician to see a family planning care provider.
4. Out-of-Area Care
If you are outside of the BCBSTX service area and require non-emergency treatment, contact one of the following immediately:
- Your primary care physician (the name and phone number are on your BCBSTX ID card)
- Contact BCBSTX Customer Service at 1-888-657-6061 or TTY 711.
- Call the Nurse Advice Line at 1-844-971-8906. (TTY 711)
Use the emergency room (ER) only for emergencies. You will have to pay for those services if you do so. We do not pay for regular ER visits.
Options for Medical Care
There are various options for medical care; some are given below.
Call Bilingual Nurse line: Bilingual Nurses (English and Spanish) are accessible 24 hours a day, seven days a week. When you or a family member has a health problem or worry, get assistance evaluating some possibilities.
Calculate Treatment Costs: You may compare prices by logging in to Blue Access for MembersSM (BAMSM) and using the cost estimator feature before seeking care.
5. Understand Your Health Plan’s Network
HMOs and PPOs employ specific groupings of doctors, hospitals, and other healthcare professionals to provide a comprehensive range of covered healthcare services. These are known as provider networks. When looking for a provider, it’s critical to understand your network and your options.
The front of your Blue Cross and Blue Shield of Texas (BCBSTX) member ID card displays our health plan or network. Call the customer care number on your member ID card if you have any queries regarding which network you have.
HMO Health Plan Member Suggestions
Always consult your primary care physician (PCP) first:
When you apply for health insurance, you will pick or be assigned a primary care physician (PCP). Your primary care physician is frequently a collaborator in keeping you healthy. A physician can act as your child’s primary care physician. A female member’s PCP can be a Gyn.
Request a referral for a specialist:
If you require medical attention for a specific issue, your primary care physician will refer you to a specialist. Check Provider Finder to ensure that the specialist is part of your network. You do not need a recommendation from your primary care physician to see an in-network OB/GYN.
Request For Prior Authorization:
Your health care professionals usually manage prior authorization before they provide treatment. However, it’s always good to double-check that your suppliers have the necessary approval.
If your providers are not in the network, you must obtain prior authorization. If you do not, we may be unable to reimburse the fee. To ensure that your supplier is in the network. You or your provider can renew prior authorization up to 60 days before it expires.
Stay in-network.:
In most cases, you will be responsible for the full cost of your care if you visit a doctor or a hospital not in your network. Find doctors, specialists, hospitals, and pharmacies in your network. You can also check if labs or imaging centers are in your network before testing.
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