News

The Inside Story Provider Newsletter

Welcome to your guide for important provider information.
Provider manual

Network plans

​​​​​​​​​​​​​Plan descriptions, sample ID card, service areas and useful contact information.

Medicare

Commercial

Medicaid

Employee Plan

Account management 

Our Provider Relations Team is here for you, no matter where you're located. If you have questions or need support, visit the contact us page and view the provider relations representative territory map to find the right contact.

Manage existing provider account

Prior authorization

Prior authorization (sometimes referred to as pre-certification or pre-notification) determines whether non-emergent medical treatment is medically necessary, is compatible with the diagnosis, member benefits, and if the requested services are to be provided in the appropriate setting.

Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Baylor must still process a provider’s 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

Medical prior authorization requests

  • Essential information

    Providers must submit the prior authorization request form. The form must include the following information to initiate the prior authorization review process:

    • Member:
      • Name
      • Date of birth
      • Number
    • Requesting provider:
      • Name
      • National Provider Identifier (NPI)
      • Dated signature
    • Rendering provider:
      • Name
      • NPI
      • Tax ID
      • Group NPI (if applicable)
    • Service requested:
      • Current Procedural Terminology (CPT)
      • Healthcare Common Procedure Coding System (HCPCS)
      • Current Dental Terminology (CDT)
      • Start and end date(s)
    • Quantity of service units requested based on the CPT, HCPCS or CDT requested

    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.

    For information regarding prior authorization submission process for drugs obtained under the MEDICAL benefit, refer to medical authorization requests.

    For information regarding prior authorization submission process for drugs obtained under the PHARMACY benefit, refer to drug requests - prior authorizations, exceptions and appeals.

  • Supporting clinical documentation

Important updates

Baylor Scott & White Health Plan requires receipt of a written complaint from a provider within 60 days of the specific event on which the complaint is based. Provider complaints can be sent to:

Baylor Scott & White Health Plan
Attn: Appeals and Grievances
1206 W. Campus Drive
Temple, TX 76502

Baylor Scott & White Health Plan (BSWHP) uses GuidingCare, a medical management platform that includes a provider portal to enhance provider experience.

The authorization portal is a tool for providers to electronically submit authorizations and receive automated responses and real-time updates. This new process is expected to shrink turnaround times by eliminating time-consuming faxes and phone calls.

Providers can check the status of authorizations, add supporting documentation, withdraw requests and make updates in an easy-to-use interface. You can find more info in the GuidingCare authorization user guide.

Providers will continue to log into the current provider portal to initiate an authorization and will be transferred—via a single sign-on—to the GuidingCare portal to complete the authorization request upon entering valid information.

Effective immediately

Purpose of this notice is to educate and inform all providers on Clinical Laboratory Improvement Amendments (CLIA) certificate requirements in order for your claims to be processed correctly.

CLIA is required for all facilities or providers that examine "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of human beings." If a facility or provider performs tests for these purposes, they are considered a laboratory and must obtain a CLIA certificate in accordance with CLIA laws and regulations.

Plan is requesting all laboratory providers to submit your most current and updated CLIA certificate.

Laboratory servicing providers who do not meet the CLIA billing requirements will not be reimbursed.

You may submit these via email to hpcliaupdate@bswhealth.org.

If you have any questions you can contact our Provider Services Center at 844.633.5325.

View this month's featured areas of our health talk.

Colorectal cancer is one of the leading causes of cancer deaths, but the good news is: It's preventable and treatable when caught early. Join us in the fight for better outcomes - your support can make a world of difference for your patients and our members. Please view, Take control of your health; Get Screened for Colorectal Cancer flyer that can be distributed to your patients.

Previous Health Talk topics

To assist you with claims processing, refer to the IVR & provider portals guide.

As we continue transitioning to a new claims system, verify eligibility by using the portal listed on the member's ID card. Most members can be verified through swhpprovider.firstcare.com. Otherwise, visit portal.swhp.org/providerportal.

BSW Care Managers can help you with appointments, medications, understanding your kidney care plan and more.

Call 844.279.7589, 7 AM to 9 PM weekdays and 9 AM to 7 PM weekends.

  • Clinical practice guidelines: View the Quality improvement: Clinical guidelines which are resources intended to optimize patient care.
  • Accessibility of services requirements: Primary Care Providers (PCPs), Specialty Providers and Behavioral Health (BH) Providers are required to provide members timely access to care. For information on appointment and access standards and after-hour requirements for practitioners view the Accessibility of services requirements.

Baylor Scott & White Health Plan (BSWHP) is pleased to announce our partnership with Zelis as a new payment vendor for SteadyFund claims payments.

Zelis offers two options for receiving electronic payments and remittance. You may select the option that works best for your practice:

  • Zelis Payments
  • ePayments

You can identify SteadyFund members by their ID card.

Opting in/out:

  • If you have already signed up to receive electronic payments from Zelis, no action is necessary.
  • If you have not signed up, you may enroll today by calling Zelis at 855.774.4392 or emailing them at help@epayment.center.
  • If you choose not to sign up, you will be paid via paper check beginning February 1, 2026.

Claim redetermination process change

The Baylor Scott & White Employee Plan claim redeterminations process on the provider portal has changed. The new process is the Provider Claim Review Request and is available to providers via the Provider Service Center at 833.542.8179.

Effective Feb. 1, 2024 — for claim redeterminations with a date of service beginning Jan. 1, 2024 — you may contact the Provider Service Center for a Provider Claim Review Request. Through the new process, you can get detailed claim analysis, real-time adjustments on most claims and a quick follow-up rather than submitting through the provider portal.

The process for redeterminations on claims with a date of service prior to the 2024 calendar year will remain unchanged.

LOB Date of service Process
EE Plan Jan. 1, 2024 and after Call 833.542.8179 for a Provider claim review request
EE Plan Prior to Jan. 1, 2024 Submit request through provider portal or by mail, as before.
Medicare and Medicaid Any date Submit through provider portal or by mail.

Please continue to use the IVR and the provider portal for benefits, eligibility and basic claims status.

UPDATE

The claim redeterminations process on the Provider Portal for Commercial* plans is changing. The new process is now the Provider Claim Review Request and will be available to providers via the Provider Service Center.

Effective Aug. 14, 2023, you may contact the Provider Service Center at 833.542.8179 for a Provider Claim Review Request which includes detailed claim analysis, real-time adjustments on most claims and quick follow-up rather than submitting through the provider portal.

Please continue to use the IVR and the provider portal for benefits, eligibility and basic claims status.

There are no changes to the Medicare and Medicaid claim appeals and redeterminations process. For Medicare and Medicaid claim appeals and redeterminations, maintain the current process of submitting through the provider portal or by mail.

Note: BSWH Employee plan is not included.

UPDATE

The claim redeterminations process on the Provider Portal for Commercial and BSWH Employee plans is changing. The new process is now the Provider Claim Review Request and will be available to providers via the Provider Service Center.

Benefits of the Provider Claim Review Request include detailed claim analysis, real-time adjustments on most claims and quick follow-up.

Effective Aug. 14, 2023, you may contact the Provider Service Center for Commercial and BSWH Employee claims for assistance, rather than submitting through the provider portal. New phone numbers will be provided to you prior to Aug. 14.

Please continue to use the IVR and the provider portal for benefits, eligibility and basic claims status.

There are no changes to the Medicare and Medicaid claim appeals and redeterminations process. For Medicare and Medicaid claim appeals and redeterminations, maintain the current process of submitting through the provider portal or by mail.

Effective July 17, 2023, the process for submitting claim appeals/redeterminations for Commercial and BSWH Employee plans has changed. If you have a redetermination request or claim appeal, contact the Provider Service Center at 844.633.5325 for Commercial claims or 800.655.7947 for BSWH Employee Plan claims for assistance, rather than submitting through the provider portal. Please continue to use the IVR and the provider portal for benefits, eligibility and basic claims status.

There are no changes to the Medicare and Medicaid claim appeals and redeterminations process. For Medicare and Medicaid claim appeals and redeterminations, maintain the current process of submitting through the provider portal or by mail.

Complaints & appeals

Quality improvement 

National Committee for Quality Assurance (NCQA) Accreditation is a comprehensive evaluation of health plans' clinical measures and consumer experience measures. Standards are developed with the help of health plans, providers, insurance customers, unions, regulatory agencies and consumer groups. NCQA's Health Plan Accreditation is considered the industry's gold standard. NCQA Accreditation measures five areas of performance: Staying Healthy, Getting Better, Living with Illness, Access and Service and Qualified Providers. See how BSWHP Providers measured up:

Healthcare Effectiveness Data & Information Set (HEDIS®)

HEDIS® is a registered trademark of NCQA. BSWHP uses HEDIS® to measure clinical quality performance and evaluate areas of care: preventive services, treatment of acute illness, management of chronic illnesses and patient experience with services provided (as measured through the CAHPS, a standardized survey used by all plans).

Quality at a glance

BSWHP is committed to delivering high-quality, safe, affordable and equitable care for all members. Our Quality Improvement (QI) Program applies to all products and focuses on improving health outcomes, member experience and access to care.

How we measure quality

We use nationally recognized tools to monitor performance and identify opportunities for improvement, including:

  • HEDIS® to track preventive care, chronic condition management and care coordination.
  • CAHPS® surveys to understand member experience and satisfaction.
Our quality focus areas
  • Better health outcomes: Preventive care, chronic condition management, behavioral health and population health initiatives.
  • Patient safety: Evidence-based guidelines, medication safety and monitoring of quality-of-care concerns.
  • Access & affordability: Improved care coordination, appropriate use of services and timely access to care.
  • Member experience: Listening to member feedback and improving service and communication.
  • Equity & inclusion: Culturally and linguistically appropriate services, language assistance and reducing health disparities.
Our commitment to members & providers

BSWHP strives for personal differentiation by placing members at the center of everything we do. We actively support members in navigating the healthcare system and partner closely with providers to improve care coordination and outcomes. As a regional health plan, BSWHP is uniquely positioned to align incentives, identify opportunities for improvement and support seamless care delivery across providers and settings.

Continuous improvement

We regularly review performance data, work closely with providers and evaluate our results to meet or exceed standards set by NCQA, CMS, TDI and HHSC—and, most importantly, to better serve our members.

Quality Improvement Subcommittee

The Quality Improvement Subcommittee (QIS) supports the Health Plan's Board of Directors by providing focused oversight of quality programs, performance measures, and improvement initiatives across all lines of business. The QIS is a multidisciplinary committee that monitors and supports clinical quality, service quality, and member experience activities for Baylor Scott & White Health Plan and its subsidiaries. The QIS reviews quality performance, approves key program documents, and promotes continuous improvement to ensure safe, effective, and equitable care for members

Key functions & responsibilities
  • Reviewing and approving the Quality Improvement (QI) Program Description, Work Plan and Annual Evaluation, as well as the Cultural and Linguistically Appropriate Services (CLAS) Plan
  • Providing oversight of clinical and service quality performance, including HEDIS® results and other quality indicators
  • Monitoring performance against clinical practice guidelines, national benchmarks and internal quality targets
  • Reviewing clinical studies, satisfaction surveys and quality performance reports
  • Identifying performance gaps and initiating or monitoring corrective actions
  • Reviewing and approving new or updated clinical practice guidelines
  • Assisting with the development, review and maintenance of clinical policies and procedures
  • Approving criteria used for authorization and utilization management decisions at least annually
  • Reviewing reports and recommendations from related committees, including Credentialing, Utilization Management and Pharmacy & Therapeutics
Committee structure

The QIS is chaired by the Chief Medical Officer and includes leadership, clinical, operational and provider representation, such as:

  • Chief Medical Officer (Chair)
  • Medical Directors
  • Vice President of Clinical Excellence
  • Vice President of Health Services
  • Vice President of Pharmacy
  • Vice President of Network Development
  • System and Director-level Quality leadership
  • Customer Advocacy leadership
  • Quality Alliance physician representation
  • Practicing primary care and specialty providers
  • Additional subject-matter experts and staff participate as needed to support committee activities.
Meeting schedule & quorum

The QIS meets at least every other month.

A quorum is met when more than one half of voting members are present. Meetings may occur without a quorum; however, formal voting cannot take place.

X
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.
Confirm