Frequently Asked Questions

First, create an account. Fill in all required fields. After your request has been processed and authorized, you'll be emailed a username and password.

If you are requesting claims access, please submit separate requests for each provider in your office that bills separately. If you're only requesting member eligibility access, only one request is needed.

Also, you may refer to the Provider Portal Training Guide.

1. Go to Provider Access
2. Select To register as a Provider click here
3. Fill out all required fields under Provider Information
4. Select Next
5. Fill out all required fields under User Information
6. In the User Preferences box, select what you need access for
   • Do you have authorization to view eligibility searches? Select "YES" or "NO"
   • Do you have authorization to view claims? Select "YES" or "NO"
7. Press Submit
   • If your information is in our system, you'll be prompted to log in to the site
   • If your Provider ID and Tax ID isn't in our system, you'll receive a message with a Request ID #. You'll be notified by email when your request for access is approved. Please keep your Request ID # for future reference

1. Go to Provider Access
2. Enter your Username
3. Enter your Password
4. Press Enter

To reset your password, go to our Request Password page.

1. Select Member Eligibility from the Members tab and the Members Eligibility Inquiry page will display
2. Enter the Member's Date of Birth and Last Name in the Search Section
3. Press Search to retrieve the results
4. Press Cancel to return to the Provider homepage

1. Select Claims Status Search from the Claims tab and the Claims Status Inquiry page will display
2. Enter the required information in the Patient/Subscriber Information section
3. Press Search to display the Explanation of Payment (EOP) List page
4. Press the Claim Number link to see its Claims Status Response page. If you cannot find a specific claim, it may be because:
   • We haven't received the claim
   • There may be an issue with the claims clearinghouse
   • The claim is billed with a provider number/NPI number that you don't have clearance to view
   • The claims clearinghouse did not send the claim to us
5. Press Cancel to return to the Provider homepage

If you can't find the Summary of Benefits (SOB) PDF through the site, please call our Provider Relations Department at 800.321.7947 and provide the group name and group number.

Enter the member's appointment date or any previous date to verify the actual date the member eligible with us. The member number is specific to the group or individual plan the member is enrolled in.

You can also try to perform a name search using the member's first and last name under the Member No. box to see if the member was enrolled in another group or individual plan.

Log into the provider section of MyBenefits for a listing of preauthorization requirements by line of business. Services, procedures, drugs and durable medical equipment that require preauthorization must be medically necessary and meet BSWHP coverage criteria.

A prior authorization is needed if you plan to refer a member out of the BSWHP network.

Formularies are a list of covered drugs required for a quality treatment program. Formularies are developed by a Pharmacy and Therapeutics Committee (P&T). The P&T Committee reviews drugs for inclusion based on safety and effectiveness. Once safety, effectiveness and place in therapy are evaluated, then overall cost of the drug therapy is considered.

Our procedures describe the method for managing the drug formularies to provide the most cost-effective therapy options.

Prior Authorization: We may require prior authorization for certain drugs. This means approval may be needed before prescriptions can be filled.

Quantity Limits: For safety and cost reasons, certain drugs have limits on the amount of the drug that BSWHP will cover at one time. This is often based on the manufacturer's recommended dosages and may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, we require the member to try certain drugs first to treat the medical condition before another drug will be covered for that condition. For example, if Drug A and Drug B both treat the medical condition, BSWHP may not cover Drug B unless Drug A is tried first. If Drug A does not work, we'll then cover Drug B.

The formularies include drugs that are covered under the prescription benefit. The formularies are tiered, meaning there are different copayments for different drugs dependent upon cost and place in therapy.

Drugs not on the formulary may be covered if:

• The drug is medically necessary
• The plan rules are followed
• The drug is not considered an excluded drug

Excluded drugs are not covered by BSWHP. For example, a drug used for cosmetic purposes may be considered an excluded drug. Please review an Evidence of Coverage (EOC) document and other plan materials to determine which drugs are excluded from coverage.

Review our drug listings to find out if a drug has additional requirements or limits.

Formularies are developed by a P&T Committee that evaluates the safety and efficacy of drugs within each therapeutic category.

An effective cost-containment approach is selecting the preferred therapeutic agent(s) within each drug class. The preferred agent(s) in a category are chosen based on efficacy, safety and the therapeutic benefit/cost ratio. Prescribing preferred agents help ensure cost effective therapy for the member and the Health Plan.

Formularies are developed by a P&T Committee that evaluates the safety and efficacy of drugs within each therapeutic category.

An effective cost-containment approach is selecting the preferred therapeutic agent(s) within each drug class. The preferred agent(s) in a category are chosen based on efficacy, safety and the therapeutic benefit/cost ratio. Prescribing preferred agents help ensure cost effective therapy for the member and the Health Plan.

The formularies guide prescription drug coverage for patients with BSWHP prescription drug benefits. Please refer to the formularies when prescribing for your BSWHP patients. The formularies are not a substitute for the professional and clinical judgment of the prescriber.

For those members with a BSWHP Prescription Drug Benefit Rider, the Health Plan will provide coverage for drugs included on the formularies in accordance with plan rules and other utilization management restrictions.

Drugs not on the formulary may be covered if:

• The drug is medically necessary
• The plan rules are followed
• The drug is not considered an excluded drug

• Drug Requests - Prior Authorizations, Exceptions & Appeals