Provider Directory
Members can choose a PCP by calling Member Services at 1-855-897-4448. RightCare’s Provider Directory lists all in-network PCPs. You may ask for one to be mailed to you by calling Member Services at 1-855-897-4448. You may also view the Provider Directory here.
Specialty Providers Referrals — Referrals are needed to see most RightCare specialty provider. A referral is an approval from your PCP for you to get specialty care and follow up treatment. If you receive services from a specialist without your PCP’s referral, or if the specialist is not a RightCare provider, you might be responsible for the bill. You can get some services without going to your PCP first. These include:
- 24-hour Emergency Care (if you feel you have a true medical emergency)
- Routine Vision Care
- Dental Services (for children)
- OB/GYN Care
- Family Planning Services and Supplies
- Behavioral (Mental) Health and Substance Abuse Services
- Texas Health Steps
You can appeal a decision if Medicaid covered services are denied based on lack of medical need.
If you have a complaint, please call us toll-free at 1-855-897-4448 to tell us about your problem.
File a Complaint
Click here.
Mindoula - Behavioral Health Support
Who qualifies?
Active Scott and White Health Plan STAR members qualify based on certain conditions. Mindoula will reach out to you if you qualify.
How can Mindoula help?
Mindoula is a behavioral health management vendor that provides tech-enabled (digital) 24/7 case/care management and psychiatric support to members with behavioral health challenges and multiple medical needs.
Programs provided by Mindoula and their StrongWell Program:
- Interpersonal Violence Reduction Program (IVRP)
- Suicide Prevention Program (SPP)
- SUD (Substance Use Disorder) Exposed Pregnancy (SEPP)
- Substance Exposed Living Program (SELP)
Papa Pals - Extra Support for New Moms
Who qualifies?
Papa Pals is for active Scott and White Health Plan STAR members from birth to one year of age and pregnant STAR members. You can receive up to 120 hours of service per year.
How can Papa Pals help?
- Social support
- Home visits
- child care assistance
- Meal preparation
- Laundry and light cleaning
- Grocery and prescription delivery
- Short-distance travel for errands and appointments
- And more
How can I get Papa Pals?
- You may receive a phone call from Papa Pals. They can sign you up during the phone call.
- You can call Papa Pals to sign up. Phone number: 1-888-345-2619; TTY users, please call 711. Business hours are 7 a.m. – 10 p.m. from Monday – Friday and 7 a.m. – 7 p.m. on Saturday and Sunday. (Tell them you are a member of Scott and White Health Plan.)
Pharmacy & Drugs
RightCare members can access prescriptions through any pharmacy that is contracted with Navitus Health Solutions. Navitus administers prescription benefits for RightCare STAR Members. For pharmacy questions, contact Customer Service at 1-855-897-4448.
You can view your pharmacy directory using the links below:
Formulary
RightCare uses the state mandated STAR formulary. The formulary is available on the Medicaid Drug Vendor Drug Program website.
The Texas STAR Formulary is available in paper form without charge. To request a copy, please call RightCare Customer Service at 1-855-897-4448.
Prior Authorizations
To obtain a prior authorization, providers should call Navitus at 1-877-908-6023. For a listing of clinical edits implemented by RightCare, click here. For access to RightCare's prior authorization forms, please click here.
- Download the State of Texas Standard Prior Authorization Form.
- If your doctor cannot be reached to approve a prescription, you can get a three-day emergency supply of your medication. Call RightCare at 1-855-897-4448 for help with your medications and refills.
Prior authorization is sometimes called pre-certification or pre-notification. Prior authorization verifies whether medical treatment that is not an emergency is medically necessary. It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Baylor will also verify if the Member has benefits.
Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Baylor must still process a Providers claim to determine if payment will be made. The claim is processed according to:
- Eligibility
- Contract limitations
- Benefit coverage guidelines
- Applicable State or Federal requirements
- National Correct Coding Initiative (NCCI) edits
- Texas Medicaid Provider Procedures Manual (TMPPM)
- Other program requirements, as applicable
Prior Authorization Requests: Essential Information & Supporting Clinical Documentation
Providers must submit the Prior Authorization Request Form, which you can view and download here. The form must include the following information to initiate the prior authorization review process:
- Member name
- Member date of birth
- Member number
- Requesting provider name
- Requesting providers National Provider Identifier (NPI)
- Rendering providers name
- Service requested:
- Current Procedural Terminology (CPT)
- Healthcare Common Procedure Coding System (HCPCS)
- Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
- Requesting Providers Dated Signature
Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted. To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.
Supporting Clinical Documentation
Lack of Information
When RightCare receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
- RightCare will notify the Member by letter that an authorization request was received but cannot be acted upon until RightCare receives the missing documentation/information from the requesting Provider. The letter will include the following information:
- A statement that RightCare has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- Timeline for the provider to submit the missing information.
- Contact information and modes of communication for provider inquiry if necessary.
- RightCare will contact Provider via fax or phone and request documentation for completion of the medical necessity review within three business days of RightCare receipt of request (where applicable).
- If RightCare does not receive the documentation/information by the end of the third business day of our request to the requesting Provider, the request will be submitted to the Medical Director no later than the seventh business day after receipt of request (where applicable).
- RightCare will render a decision no later than the tenth business day after the request received date.
Member Forms
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- RightCare by Scott and White Health Plan has received Accreditation from the National Committee for Quality Assurance (NCQA). This means that RightCare by Scott and White Health Plan's service and clinical quality meet the basic requirements of NCQA's rigorous standards for consumer protection and quality improvement. Consumers can easily access organizations' NCQA statuses and other information on healthcare quality by visiting ncqa.org or calling NCQA Customer Support at 888-275-7585.
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