Authorizations and Referrals

To receive the maximum benefit from your Scott and White Health Plan (SWHP) medical plan, you will need to use SWHP-approved doctors, hospitals, pharmacies, and other providers of medical services that are covered by your plan. In the event of an emergency, it is important that you go to the nearest hospital that can provide the best care for your needs. In this case, you may use doctors or hospitals outside the SWHP network.

When you need non-emergency medical services you always have the choice of using out-of-network providers. However, you will not receive the benefits of your SWHP medical plan, and you will be responsible for the full cost of any medical services you receive.

Most services you need are available through the Scott & White Healthcare system. Referrals are no longer required by SWHP, however, some specialists may require it. Some services may also require your physician to ask SWHP for prior authorization. If you want to be sure SWHP will pay for this service, you will need prior authorization before these procedures are performed. When authorization is given, SWHP will provide coverage for these services based on the terms of your specific plan.

All services must be medically necessary and appropriate and meet Scott and White Health Plan coverage criteria where applicable. If your plan does not offer an out-of-network benefit, all services must be rendered by in-network physicians/providers (unless otherwise authorized in advance) in order to be eligible for payment.

If you have questions about referrals or prior authorizations, please contact our Customer Advocacy Team at 1-800-321-7947 or submit a request for assistance online.