Wait. I need a primary care provider?

Wait. I need a primary care provider?

August 7, 2019
Female patient with female docWith a new plan year less than a month away, are you prepared to make the most of your health benefits? HealthSelect of Texas® and Community First Health Plans require all participants to choose a primary care provider (PCP) – for their own good and for the good of the plan.

Managing your health care

Your PCP is responsible for coordinating your health care. He or she gets to know you, your medical history and your lifestyle. If you have a medical issue, your PCP can often make it easier and faster to get the care you need, including making referrals for you to see specialists and writing orders for lab and imaging services. 

Remember, your PCP should refer you to in-network specialists, laboratories and other providers. Still, you should always confirm that the referral is to an in-network provider before you go. Making a quick call to your health plan or the provider to check the network status can significantly reduce your out-of-pocket expenses.

Reducing costs

Having a PCP doesn’t just benefit you, however. Evidence shows that when PCPs coordinate care for plan participants, it reduces costs and helps keep the plan affordable, so you don’t face big hikes in premiums and out-of-pocket costs.
In HealthSelect of Texas, you do not need a referral for the following providers, but be sure to confirm that they’re in the HealthSelect network before your visit:
  • Chiropractic visits
  • Eye exams (both routine and diagnostic)
  • Mental health counseling
  • OB/GYN visits
  • Occupational therapy, physical therapy and speech therapy
  • Virtual visits, urgent care centers and retail health clinics

HealthSelect of Texas

The process: If you are enrolled in HealthSelect of Texas, you must choose a PCP and notify Blue Cross and Blue Shield of Texas (BCBSTX) of your choice within 60 days of your medical coverage start date. (BCBSTX is the company that manages the HealthSelect plans for ERS.) Once your PCP information is updated, you will get a HealthSelect of Texas ID card with your PCP’s name listed.

After 60 days, if you still have not notified BCBSTX of your PCP choice, out-of-network benefits will apply to any services you get, even if the provider is in the network. This means your share of the costs will be higher. (If you miss the 60-day deadline, you can still name a PCP at any time. Once BCBSTX updates your information, you’ll start getting in-network benefits when you see in-network providers and get referrals when needed.)
 
  • Referrals: If you need to see a specialist, your PCP will need to get a referral for you from BCBSTX. If a referral is not on file with BCBSTX before your specialist visit, your services will be considered out-of-network and you will pay more, even if the provider is in the HealthSelect network.
  • Prior authorizations: In addition to referrals from your PCP, some services need prior authorization from BCBSTX. These include, but aren’t limited to inpatient hospital stays, surgery and durable medical equipment. In general, in-network providers are responsible for getting a prior authorization before they provide this type of service to you. To see the full list of services that require prior authorization, read your plan’s Master Benefit Plan Document under the Publications tab on the HealthSelect website
  • How to make your choice: You can choose or change your PCP by calling a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 or by logging in to Blue Access for MembersSM:
    1. If you already have a Blue Access for Members account, log in using your username and password, otherwise, register for Blue Access for Members following the instructions on the screen.
    2. Once you’re logged in, go to the “Doctors and Hospitals” tab.
    3. Click “Select Primary Care Physician.”
    4. Once you make your selection, BCBSTX will mail you a new medical ID card with your PCP’s name.

If you have any questions about your benefits or need help finding an in-network PCP, call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday–Friday 7 a.m. - 7 p.m. or Saturday from 7 a.m. to 3 p.m. CT. If you prefer to chat online, log in to Blue Access for Members from the HealthSelect website.

HMOs

Community First Health Plans

If you have enrolled in Community First Health Plans, you must choose a PCP. Your PCP will be the first person you and your dependents go to when you need preventive care, such as immunizations, or are sick and need medical advice.
 
Community First does not require a referral for the following services:
  • Mental health services and counseling
  • OB/GYN services
  • Vision exams from an optometrist or ophthalmologist
  • OB/GYN visits
  • Family planning services

Each of your dependents can choose their own PCP from the Community First Participating Provider directory.

Reminder: If you do not chose a PCP, Community First will choose one for you.

Community First does not require a referral to see a specialist, but some specialists ask for a referral from your PCP before meeting with you. Check with your PCP to find out if a particular specialist requires a referral. Additionally, some services require authorization from Community First in advance. Your PCP will take care of these prior authorizations for you.

Call Community First Health Plans' Member Services if you need assistance finding a provider or scheduling an appointment at (210) 358-6262 or toll-free at (877) 698-7032.
 

Scott and White Health Plan

Because Scott and White Health Plan is an open-access HMO, you can go to any in-network provider without a referral. However, you can choose an in-network PCP if you want. If you do, your PCP will be the one you call when you need medical advice, when you are sick and when you need preventive care such as immunizations or physicals.

If your PCP is unavailable when you need service, you can see any other providers who work in the same clinic as your PCP.

If you  have questions or need help, call the Customer Service line, toll-free at (800) 321-7947 7 a.m. - 7 p.m. CT, Monday - Friday.