FirstCare Form

FirstCare Medicaid (STAR & CHIP) FirstCare Health Plans, part of Baylor Scott & White Health Plan offers Medicaid STAR in the Lubbock service area and the West Medicaid Rural Service Areas (MRSA); we offer CHIP in the Lubbock service area. Name Name Name Name (Nombre): MEMBER INFO MEMBER INFO MEMBER INFO MEMBER INFO (Información del Miembro) Member # Member # Member # Member # (N.° de miembro): SMPL0001 Sex Sex Sex Sex (Sexo): DOB DOB DOB DOB (Fecha de nacimiento): JOHN SAMPLE Name Name Name Name (Nombre): PCP PCP PCP PCP (Proveedor de atención primaria) Effective Date Effective Date Effective Date Effective Date (Fecha efectiva): Network Network Network Network (Red): Group (Grupo): Group # (N.° de grupo): Service Area (Área de servicio): Benefit Effective Date (Fecha efectiva de beneficios): Navitus Navitus Navitus Navitus: 877-908-6023 BIN: BIN: BIN: BIN: 610602 PCN: PCN: PCN: PCN: MCD GRP: GRP: GRP: GRP: FCH PHARMACISTS ONLY PHARMACISTS ONLY PHARMACISTS ONLY PHARMACISTS ONLY See back for additional information. Vea el dorso para obtener información adicional. FOR PROVIDERS FOR MEMBERS Electronic Claims: Electronic Claims: Electronic Claims: Electronic Claims: • Availity/Healthsmart: • 94999

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• P: TH003 I: 12T03 Paper Claims: Paper Claims: Paper Claims: Paper Claims: FirstCare STAR PO Box 211342 Eagan, MN 55121-1342 In case of emergency, call 911 or go to the closest emergency room. In case of emergency, call 911 or go to the closest emergency room. In case of emergency, call 911 or go to the closest emergency room. In case of emergency, call 911 or go to the closest emergency room. After treatment, call your/your child's PCP within 24 hours or as soon as possible. • Customer Service: 800-431-7798 Customer Service: 800-431-7798 Customer Service: 800-431-7798 Customer Service: 800-431-7798 (TTY: 711) • 24/7 Behavioral Health Crisis: 800-327-6943 • 24/7 Nurse Line: 855-828-1013 • Self-Service Portal: my.FirstCare.com • Provider Directory: FirstCare.com/FindAProvider PARA MIEMBROS En caso de emergencia, llame al 911 o vaya a la sala de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencia más cercana. más cercana. más cercana. más cercana. Después del tratamiento, llame a su médico o al médico de su niño/a dentro de las 24 horas o tan pronto como sea posible. • Servicio al cliente: 800-431-7798 Servicio al cliente: 800-431-7798 Servicio al cliente: 800-431-7798 Servicio al cliente: 800-431-7798 (TTY: 711) • Línea para crisis de salud conductual 24/7: 800-327-6943 • Línea de enfermeras 24/7: 855-828-1013 • Portal de autoservicio: my.FirstCare.com • Directorio de proveedores: FirstCare.com/FindAProvider Prior Authorization: Prior Authorization: Prior Authorization: Prior Authorization: is mandatory for inpatient elective admissions. For authorizations, call 800-884-4905 or go to FirstCare.com/STAR. Card Issue Date: 11/19/2024 FirstCare.com/STAR FirstCare.com/STAR FirstCare.com/STAR FirstCare.com/STAR Name Name Name Name (Nombre): Name Name Name Name (Nombre): Network Network Network Network (Red): See back for additional information. MEMBER INFO MEMBER INFO MEMBER INFO MEMBER INFO (Información del Miembro) COPAYS COPAYS COPAYS COPAYS (Copagos) PCP PCP PCP PCP (Proveedor de atención primaria) Navitus Navitus Navitus Navitus: 877-908-6023 BIN: BIN: BIN: BIN: 610602 PCN: PCN: PCN: PCN: MCD GRP: GRP: GRP: GRP: FCH Office Visit Office Visit Office Visit Office Visit (Visita de la oficina): Inpatient Admission Inpatient Admission Inpatient Admission Inpatient Admission (Admisión hospitalaria): Emergency Room Emergency Room Emergency Room Emergency Room (Sala de emergencias): Rx Generic/Rx Brand Rx Generic/Rx Brand Rx Generic/Rx Brand Rx Generic/Rx Brand (Rx genéricoca/Rx marca): Vea el dorso para obtener información adicional. Group (Grupo): Group # (N.° de grupo): Service Area (Área de servicio): Benefit Effective Date (Fecha efectiva de beneficios): Member # Member # Member # Member # (N.° de miembro): SMPL0001 Sex Sex Sex Sex (Sexo): DOB DOB DOB DOB (Fecha de nacimiento): JOHN SAMPLE Effective Date Effective Date Effective Date Effective Date (Fecha efectiva): PHARMACISTS ONLY PHARMACISTS ONLY PHARMACISTS ONLY PHARMACISTS ONLY TDI FOR PROVIDERS FOR MEMBERS Electronic Claims: Electronic Claims: Electronic Claims: Electronic Claims: • Availity/Healthsmart: • 94999

•  Change Healthcare

• P: TH003 I: 12T03 Paper Claims: Paper Claims: Paper Claims: Paper Claims: FirstCare CHIP PO Box 211342 Eagan, MN 55121-1342 In case of emergency, call 911 or go to the closest emergency room. In case of emergency, call 911 or go to the closest emergency room. In case of emergency, call 911 or go to the closest emergency room. In case of emergency, call 911 or go to the closest emergency room. After treatment, call your/your child's PCP within 24 hours or as soon as possible. • Customer Service: 877-639-2447 Customer Service: 877-639-2447 Customer Service: 877-639-2447 Customer Service: 877-639-2447 (TTY: 711) • 24/7 Behavioral Health Crisis: 800-327-6943 • 24/7 Nurse Line: 855-828-1013 • Self-Service Portal: my.FirstCare.com • Provider Directory: FirstCare.com/FindAProvider PARA MIEMBROS En caso de emergencia, llame al 911 o vaya a la sala de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencia En caso de emergencia, llame al 911 o vaya a la sala de emergencia más cercana. más cercana. más cercana. más cercana. Después del tratamiento, llame a su médico o al médico de su niño/a dentro de las 24 horas o tan pronto como sea posible. • Servicio al cliente: 877-639-2447 Servicio al cliente: 877-639-2447 Servicio al cliente: 877-639-2447 Servicio al cliente: 877-639-2447 (TTY: 711) • Línea para crisis de salud conductual 24/7: 800-327-6943 • Línea de enfermeras 24/7: 855-828-1013 • Portal de autoservicio: my.FirstCare.com • Directorio de proveedores: FirstCare.com/FindAProvider Prior Authorization: Prior Authorization: Prior Authorization: Prior Authorization: is mandatory for inpatient elective admissions. For authorizations, call 800-884-4905 or go to FirstCare.com/CHIP. Card Issue Date: 11/19/2024 FirstCare.com/CHIP FirstCare.com/CHIP FirstCare.com/CHIP FirstCare.com/CHIP FirstCare STAR FirstCare CHIP FirstCare Service Areas Lubbock Service Area (STAR and CHIP/CHIP Perinate): Carson, Crosby, Deaf Smith, Floyd, Garza, Hale, Hockley, Hutchinson, Lamb, Lubbock, Lynn, Potter, Randall, Swisher and Terry counties Medicaid Rural Service Area (MRSA) West (STAR Only): Andrews, Archer, Armstrong, Bailey, Baylor, Borden, Brewster, Briscoe, Brown, Callahan, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Concho, Cottle, Crane, Crockett, Culberson, Dallam, Dawson, Dickens, Dimmit, Donley, Eastland, Ector, Edwards, Fisher, Foard, Frio, Gaines, Glasscock, Gray, Hall, Hansford, Hardeman, Hartley, Haskell, Hemphill, Howard, Irion, Jack, Jeff Davis, Jones, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lipscomb, Loving, Martin, Mason, McCulloch, Menard, Midland, Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Palo Pinto, Parmer, Pecos, Presidio, Reagan, Real, Reeves, Roberts, Runnels, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Taylor, Terrell, Throckmorton, Tom Green, Upton, Uvalde, Val Verde, Ward, Wheeler, Wichita, Wilbarger, Winkler, Yoakum, Young and Zavala counties Pr_25NetworkFlyer-MD-FirstCare-01.25-NR Useful Information STAR Medicaid: 800.431.7798 CHIP: 877.639.2447 Find Your Provider Relations Rep Provider Quick Reference Guide