Benefit FAQs

What are my benefits for outpatient mental health?

In-network services are generally covered at 100% of the in-network rate subject to the $30 co-payment if not performed in a hospital. Out-of-network services are generally covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of-network deductible. The OTR (Outpatient Treatment Request) Form is recommended on your first visit to document your anticipated treatment plan in preparation for additional sessions. Your first 12 Mental Health treatment sessions will be paid without precertification needed. Additional sessions require pre-certification.

What are my benefits for Urgent Care services?

In-network services are covered at 100% after a $25 to $30 co-payment. Out-of-network services are covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of-network deductible.

Do I have Durable Medical Equipment coverage?

Durable Medical Equipment is covered without precertification if the Equipment is not a rental under $500. Durable Medical Equipment over $500.00 and Equipment rentals require pre-certification. In-network is covered at 100% of the network rate. Out-of-network is covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of-network deductible.

What are my benefits for acupuncture?

Acupuncture is a covered benefit that requires pre-certification. The Plan excludes acupuncture that is not medically necessary or considered to be experimental and/or investigational, for example, for the maintenance of a condition or diagnosis; smoking cessation; or weight loss.

What are my benefits for infertility treatment?

Artificial reproduction requires pre-certification and is limited to 4 Cycles per lifetime. A successful retrieval and transplantation is considered 1 Cycle. The benefit does not cover cryo-preservation, or storage and/or retrieval of cryopreserved materials unless it is related to infertility treatment (of or relating to a “Cycle”).

Am I covered for genetic testing?

Yes, genetic testing is covered under your plan and is subject to medical necessity review. In-network services, if not performed in a hospital, are covered at 100% after a $30 co-payment. Out-of-network services, if not performed in a hospital, are covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out- of-network deductible If the Quest Diagnostics Lab Network is used, In-network services are covered at 100% with no copay responsibility.

Is a mammogram or 3-D mammogram a covered benefit?

Yes, routine mammogram is a covered benefit. It does not require medical necessity between the ages of 40 and over. In-network benefits are covered at 100% of the network rate. Out-of-network benefits are covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of- network deductible. 3-D mammogram or Tomosynthesis is a covered benefit but is subject to medical necessity. In-network is covered at 100%. Out-of-network is covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of- network deductible.

What are my child’s outpatient well childcare benefits?

From birth to 1 year of age: 7 visits

From 1 through 2 years of age: 4 visits

From 3 through 6 years of age: 4 visits

From 7 through 21 years of age: 15 visits

What are my out-patient substance abuse benefits?

In-network is covered at 100% after a $25 to $30 copayment. Out-of-network is covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of-network deductible. No pre-certification is necessary for the first 12 sessions. Thereafter, any additional sessions need to be pre-certified.

My doctor has recommended I have a sleep study done. Am I able to have the test done in my own home?

Yes. Medical necessity is required.

Are travel immunizations covered?

No.

Do I have chiropractic benefits?

Yes, pre-certification is required. Medical necessity is required after the 12th visit.

Do I have physical therapy benefits?

Yes. Pre-certification is required.

Do I have coverage for breast pumps?

Yes, but hospital grade breast pumps are not covered. In-network is covered at 100% with No co-payment responsibility. Out-of-network is covered at 70% of the allowed amount or of the usual, customary, and reasonable amount (the amount paid for a= medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service) subject to the out-of-network deductible.

My doctor wants me to have a bone density test. Am I covered?

Bone density services are covered for members aged 65 and over. Prior to age 65, this benefit requires medical necessity review.

I recently consulted with an orthopedic doctor and would like a second opinion/consultation. Am I able to do that?

One consultation is covered in each specialty per calendar year for each condition being treated even if related to surgery.

Eligibility FAQs

I had a baby and need to add her to my policy. What do I need to do?

You may request enrollment for your dependent newborn no later than 30 days after the date of birth through your school district.

How do I determine coordination of benefits for my dependent?

The Primary and the Secondary Plan will be determined according to the rules under the SWSCHP Plan and can be found in the Summary Plan Description (SPD). You can find the SPD on this website.

Check FAQs

I misplaced a check that I received. Can you resend it?

Yes, a stop payment and reissue request can be placed on the check. Please allow 10-15 business days for the check to be reissued. (Original check number is given in the event the check is located so that it is not presented).

My doctor informed me they did not receive a check. Can I place a stop payment request on the check?

If the benefit was issued by Anthem we are unable to place a stop and reissue on the check. Please ask your provider to call 800-676-2583. If the benefit was issued by AEBA (Amalgamated Employee Benefits Administrators), you can contact a Care Navigator to stop and reissue the check by calling 888-779-7247 (888-P-SWSCHP).

Appeal Status FAQs

How long will it take for you to review an appeal for my denied claim?

If no additional information is needed the process will take no more than 30 days. If additional information is needed you will be contacted by the Appeals Department.

Network Provider FAQ

Is my provider in-network? How can I get a listing of in- network providers?

You can verify your provider's network status by visiting the SWSCHP website selecting:

For Members>Active Members & Pre-Medicare Retirees> Find a Doctor

You can also call the provider locator phone number listed on the back of your medical ID card.

Medical/RX ID card FAQs

I misplaced my medical card. Can AEBA send me a new one?

Yes, we can request you a replacement card to arrive in 7-10 days

My child will be going away to college. Can they have their own card?

Yes, we can request a card for them. Please allow 7-10 days for receipt.

How can I get a prescription card?

You can request a prescription card by calling CVS Caremark at 844-260-5889.

HIPAA FAQs

Why do I need HIPAA authorization to discuss claims details for a dependent if I am the member/policyholder?

Written authorization is required to obtain information for dependents over age 18. A “HIPAA Authorization to Release Information” form is available for use on the SWSCHP website under Basics>Necessary Forms.

If there is no HIPAA authorization on file, can I still obtain information for my dependent over 18?

If your dependent contacts a Care Navigator at 888-P-SWSCHP we will be able to provide details for the duration of the conversation with authorization.

I can’t find what I need on the website. Who should I contact?

You should always contact your care representatives first if you can’t find what you need on this website. This contact information is located under the For Members tab inside of your specific membership status (i.e. Active/Pre-Medicare Retiree or Retiree).