Network Plans
Plan descriptions, sample ID card, service areas and useful contact information.
Commercial
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.
- Member:
-
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.
- Claim must contain a valid CLIA certificate ID
- Servicing provider demographic information must match specific location where the provider is performing on-site lab testing and as outlined on your CLIA certificate
- Claim payments can only be made for dates of service falling within the certification dates governing the approved services
- Provider must follow CLIA guidelines as outlined by CMS (cms.gov/Regulations-and-Guidance/Legislation/CLIA) and HHSC (hhs.texas.gov/providers/health-care-facilities-regulation/laboratories-clinical-laboratory-improvement-amendments).
- For information about waived tests or to obtain a CLIA certificate of Waiver, refer to cdc.gov/lab-quality/php/waived-tests/.html
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
- Well Child Visit/Vaccines
- Diabetes Awareness Flyer
- Flu Campaign Flyer
- Importance of Medication Adherence
- Importance of Medication Adherence
- Understanding Antidepressant Medication
- ADHD Medication Adherence Flyer
- Hypertension Awareness Flyer
- Your Brain's Coach & ADHD
- First Child Check Up ADHD
- Feeling Rejected & ADHD
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.
Join us for a series of monthly Lunch & Learn presentations.
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
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).
Purpose & Scope
The purpose of the quality improvement program is to ensure BSWHP is providing the highest quality care that is easy to access and affordable to our members regardless of plan type, age, race/ethnicity or health status. BSWHP supports and tries to reach "Triple Aim" goals: improving member's affordability, quality and experience of care. BSWHP Quality programs and improvement projects are designed to improve member outcomes through systematic ongoing measurement, provider/member/health plan care coordination and continuous evaluation of results.
The scope of the QI Program is to monitor, evaluate and improve:
- The quality and safety of clinical care
- The quality of service provided by BSWHP
- The quality of practitioners and providers
- Affordable and accessible healthcare and wellness
- The overall member experience
BSWHP strives for personal differentiation. No matter the product, the member is our focus. BSWHP has many examples of helping our members navigate the maze of healthcare, as well as thoughtful interventions that have improved the health outcomes of our members. BSWHP's close connection to both our members and our provider community places us in a unique position to act as an effective member advocate. As a regional health plan, we have exceptional opportunities to finance healthcare in a way that is intrinsically superior by aligning incentives, identifying gaps in healthcare delivery and facilitating smooth and seamless coordination of care throughout the healthcare continuum.
QI Program Goals - Objectives
- Improve Member Health Outcomes - Through staying healthy and management of chronic conditions such as the following: Diabetes, Asthma, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Behavioral/Mental Health, Children's' and Women's' Health.
- Improve Medical Safety - By fostering a supportive environment that helps providers to improve the safety of their practice, monitoring BSWHP Pharmacy medication safety, monitoring medication errors and providing members with information that improves their knowledge about clinical safety in their own care.
- Increase Member Satisfaction - By prompt identification and resolution of dissatisfaction with administrative or medical processes. Evaluate processes for improvement. BSWHP conducts the CAHPS survey to measure Member Satisfaction annually. This survey is use to identify opportunities for improvement.
- Meet the Cultural and Linguistic Needs of the Member - By identifying language and other cultural/social needs of BSWHP members. We meet those needs by providing bilingual services, translated materials, cultural diversity education, training for BSWHP staff and a network of diverse and multilingual providers. BSWHP regularly monitors member demographic data and member feedback to adjust the provider network and services to reflect the member's needs.
- Provide Affordable Care - Through reducing the variations in clinical care, preventing overuse, underuse or misuse of services, redirection of care to the most appropriate place and through continued improvement of all BSWHP processes to optimize care and reduce unnecessary care.
- Organizational Effectiveness - Strive to achieve statistically significant improvements in all quality measurements to meet or exceed regional or national averages set forth by National Committee Quality Assurance, Centers for Medicare and Medicaid (CMS), Texas Department of Insurance (TDI) and Texas Health and Human Services Commission (HHSC) or other accepted quality Standards.