Coverage - Plan Information

 
Coverage - Plan Information

Preauthorization
TRS-ActiveCare requires advance approval (preauthorization) by Blue Cross and Blue Shield of Texas or INROADS Behavioral Health Services for certain services.  Preauthorization establishes in advance (or within 48 hours following an emergency hospital admission) the medical necessity of certain care and services covered under TRS-ActiveCare.  Preauthorization ensures that care and services will not be denied on the basis of medical necessity.  However, preauthorization does not guarantee payment of benefits.  Benefits are always subject to other applicable requirements, such as preexisting conditions, limitations and exclusions, payment of premium, and eligibility at the time care and services are provided. 

The following types of services require preauthorization:

  • All inpatient admissions;
  • Treatment of all mental health care, chemical dependency and serious mental illness;
  • Extended care, such as in a skilled nursing facility, through home health care or through hospice; and
  • Home infusion therapy.

Care should also be preauthorized if you or your doctor wants to:

  • Extend your hospital stay beyond the approved days (you or your doctor must call for an extension before your approved stay ends); or
  • Transfer you to another facility or to or from a specialty unit within the facility.

Note:  You must request preauthorization to use a non-network provider to receive the network level of benefits.  Preauthorization for medical necessity of services does not guarantee the network level of benefits. Even if approved by Blue Cross and Blue Shield of Texas, non-network providers paid at the network level may bill for charges exceeding the Blue Cross and Blue Shield of Texas allowable amount for covered services.  You are responsible for these charges, which may be substantial.  For example, if a non-network doctor bills $10,000 for a covered service and the Blue Cross and Blue Shield of Texas allowable amount is $4,000, assuming your deductible is met, you would pay $6,800 ($4,000 x 20% preauthorized network coinsurance = $800 plus the $6,000 exceeding the allowable amount). 

How to preauthorize

Medical:  Network providers will preauthorize services for you. 

If you do not use a network provider for your medical care, you are responsible for preauthorization by calling Blue Cross and Blue Shield of Texas at 1-800-441-9188. (The preauthorization telephone number also appears on your TRS-ActiveCare ID card.) This phone call is important.  There is a $250 penalty for failure to preauthorize a medically necessary admission to a non-network hospital. You, your provider, or a family member may call.  The call should be made between 6 a.m. and 6 p.m. (Central Time) Monday through Friday.  Calls made after working hours, on weekends, or holidays will be recorded and returned the next working day.

Mental health care, chemical dependency and serious mental illness: Preauthorization for mental health care, chemical dependency and serious mental illness should be obtained from INROADS Behavioral Health Services by calling 1-800-528-7264 between 8 a.m. and 5 p.m. (Central Time). All mental health care, chemical dependency and serious mental illness—network and non-network, inpatient and outpatient—should be preauthorized.