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Important updates

For Commercial Plans: Claim Appeal/Redetermination Process Change

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, please maintain the current process of submitting through the provider portal or by mail.

Please 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, please 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 1.844.633.5325 for Commercial claims or 1.800.655.7947 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, please maintain the current process of submitting through the provider portal or by mail.

CLIA Information/Updates

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 please 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 (www.cms.gov/Regulations-and-Guidance/Legislation/CLIA) and HHSC (www.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, please refer to the following site for more information www.cdc.gov/labquality/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.

IVR and Portals Guide

To assist you with claims processing, refer to the IVR and Provider Portals Guide.

Verifying Eligibility

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

COVID-19 Updates

Testing and Vaccination: COVID-19 testing and vaccination are available to health plan members at zero out-of-pocket cost. Click here for more information and benefit updates.
Telehealth and Prior Authorization Information: View the COVID-19 Telehealth and Telemedicine Policy for coding guidelines and claims submission procedures. We have also reduced our Prior Authorization Requirements.
Hospital Without Walls: HHSC adopted emergency rules in response to the state of disaster declared in Texas and the U.S. related to COVID-19. As part of the CMS Hospital Without Walls initiative, hospitals can provide hospital services in other healthcare facilities and sites not currently considered to be part of a healthcare facility or set up temporary expansion sites to help address the urgent need to increase capacity to care for patients, in response to the COVID-19 pandemic. Learn more.

Kidney Health Program

We've teamed up with Cricket Health to help kidney care specialists enhance the quality of life for their patients. Cricket Health's evidence-based approach can help you lower costs and improve patient engagement and key clinical outcomes for eligible members living with chronic kidney disease (CKD) or end-stage kidney disease (ESKD). To learn more, visit Cricket Health or read more here.

Home-Based Care Services

We teamed up with Landmark Health to provide BSW SeniorCare Advantage members with access to home-based care. View a summary of services Landmark provides, visit Landmark's website, learn more about program information and read the FAQ. Call Landmark to schedule a visit at 833.874.2581 (TTY: 711).

Quality Information/Updates

Health Talk: View this month's featured areas of our health talk.
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 Our Network

Interested in becoming a Baylor Scott & White Health Plan (BSWHP) contracted provider? We'd love to have you as a part of our growing network. We work with more than 36,000 providers and 4,000+ facilities in Texas to provide a high-level continuum of care, every day. And there's an even stronger commitment to providing you with digital tools that improve the patient journey. Start the application process today.

Healthcare providers

Apply to join our provider network.

Pharmacy providers

Apply to become a Commercial or Medicare pharmacy network provider by contacting Optum Provider Relations at Provider.Relations@optum.com or 877.633.4701.

Account Management

Contact us

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 - forms

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

Prior Authorization Requests: Essential Information & Supporting Clinical Documentation

Providers must submit the Prior Authorization Request Form, view and download here. The form must include the following information to initiate the prior authorization review process:

Member name
Member date of birth
Member number
Requesting provider name
Requesting provider’s National Provider Identifier (NPI)
Rendering provider’s name

Service requested:
- Current Procedural Terminology (CPT)
- Healthcare Common Procedure Coding System (HCPCS)
- Current Dental Terminology (CDT)
Service requested start and end date(s)
Quantity of service units requested based on the CPT, HCPCS, or CDT requested
Requesting Provider’s Dated Signature

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.