Prior to issuing a medical necessity denial in response to an authorization request for medical services, a representative calls the treating provider and offers to schedule a
peer-to-peer review. The review should take place prior to issuance of the denial. Baylor Scott & White Health Plan (BSWHP) requests providers to promptly respond to the
peer-to-peer request in order to ensure a timely and effective review of authorization requests for medical services.
To increase communication with BSWHP providers across all lines of business, we would like to take this opportunity to outline the regulatory requirements for peer-to-peer or P2P.
Self-Insured (regulated by ERISA): ERISA guidelines do not require P2P for self-insured policy holders, however the provider will be contacted to allow
submission of additional information prior to rendering a decision.
Medicare, Commercial (regulated by TDI), FEHB (regulated by OPM), Medicaid: Before a denial is issued, the provider of record is afforded a
reasonable opportunity to discuss the services under review during normal business hours. Providers are required to respond in a timely manner to accept the opportunity.
Contact Customer Service at 254.298.3000 if you have any additional questions.
Effective June 1, 2017, the BSWHP Health Services Department (HSD) no longer accepts retroactive authorization requests. If a service requires prior authorization and the
authorization is not obtained prior to the service being rendered, the claim for the service will be denied.
The BSWHP HSD will continue to accept retroactive notifications for the limited services that require one. A reference number will be provided for the notification. For more
information, please do not hesitate to contact the BSWHP HSD at 888.316.7947.
All BSWHP non-contracted provider requests for prior authorization are processed by
Please take the following steps to ensure your request is processed in a timely manner:
For any item on the prior authorization list, be sure to complete a prior authorization request. The forms
are based on the Texas Department of Insurance (TDI) Standardized Prior Authorization Form.
Prior authorization requests for services and drugs obtained under the medical benefit (i.e.
drug will be billed on a medical claim by a provider) are processed by BSWHP Health Services Division.
Health Services Department (HSD) does not process prior authorization requests for drugs obtained under the
pharmacy benefit (i.e. prescription drug benefit). The submission process and forms below
apply only to requests for medical benefit coverage of services and drugs.
For more information regarding prior authorization submission process for drugs obtained under the
pharmacy benefit, visit Drug Requests - Prior Authorizations,
Exceptions and Appeals.
Health Services Division accepts medical benefit prior to authorization and peer-to-peer
requests during regular business hours (8 AM to 5 PM) and any time after hours in the following ways:
Statistics regarding Prior Authorization approval and denial rates for requested services.
Each list includes statistics on:
Choose from the following policy topics below.
(in alphabetical order)
We reimburse medically necessary surgical services. See the appropriate links below to download more
information about specific policies.
In the face of escalating healthcare costs and rapid medical advancements, we're continually evaluating and
evolving our policies. We use clinical data, industry-accepted guidelines and other sources to inform our
quality measurement procedures.
We're as equally committed to supporting transparency, which helps us and our network of providers, make
informed decisions regarding the healthcare of our members.
Read more about our clinical programs and review processes.
BSWHP's Case Management Program is included in health plan coverage as an added benefit for our members. The
program is at no cost to your patient and completely voluntary. Your patient may opt in or out at any time.
Case Management Program provides:
What to expect after referring to Case Management:
A member of the Case Management team will call your patient, offer Case Management and attempt to complete a
comprehensive health assessment. Any needs or opportunities for assistance identified during the assessment
will be utilized to develop an individualized plan of care with your patient. Our staff will continue to
work with you and your patient until the goals are met, the member's coverage terminates, the member remains
unreachable or they decline to continue.
To refer your patient for the Case Management program, please email CaseManagement@BSWHealth.org.
BSWHP seeks to assist members who have experienced a critical event or diagnosis that requires extensive use
of resources. Personalized case management by an assigned Complex Case Manager facilitates a comprehensive,
multi-disciplinary approach to promote member autonomy and enhance the continuity of care and the member's
quality of life. By combining advocacy with open communications and resource management, we're able to
promote cost-effective care interventions and outcomes. Case managers help patients with chronic illnesses,
catastrophic illnesses or injuries get the most out of their healthcare.
Our program helps transfer patients to specialized treatment facilities, ensuring their care needs are met.
Patients, with support from their physician and family members, set goals that roadmap their recovery to a
healthier status. The scope of services provided include:
We believe in a better, healthier life for all. We work with members to help with their chronic illnesses or
conditions through the development of a collaborative treatment plan with their primary care provider and
ensure they are monitoring their conditions.
Our predictive modeling tool analyzes claims and pertinent data to:
Members considered medium to high risk are assigned a dedicated clinician who helps identify personal goals
and create a plan for self-management. Through education, members are empowered to take control over the
status of their health. For members in need of behavioral health services, our conditional guidance program
identifies and addresses psychosocial issues. As they demonstrate a readiness to change, we guide members to
make the behavior modifications necessary to achieve goals and improve health.
Our Utilization Management (UM) Program ensures members receive services in a timely, appropriate and cost-effective manner.
The UM Program Description details the decision-making process we use across our Commercial, Self-Insured and
Medicare lines of business. The program is evaluated and updated annually by senior management, approved by
the Quality Improvement Committee with recommendations from the Utilization Management Committee.
As a physician/health professional who practices in Texas, you have the opportunity to strengthen your
provider/patient relationships by offering telemedicine services.
Telemedicine and telehealth services are covered for fully insured commercial PPO, EPO and HMO/POS plans in
accordance with Texas Insurance Code, Chapter 1455. Reimbursement is based upon rates for equivalent
face-to-face services. Medical policies, benefits and eligibility are also determining factors for
BSWHP provides general reimbursement information and fee schedule information based upon coding. Click on the Provider Login link or Create an Account to view this information. You may also request it from your Provider Representative or by calling BSWHP.
We follow a review process for all emergency, elective and scheduled hospital admissions.
Members are covered for life-threatening urgent and emergency care at any time in any facility. If any member
requires observation or hospital admission, notify us within 24-48 hours of admission to receive
consideration of BSWHP coverage for the stay.
Call our Health Services Department at 254.298.3088 or 888.316.7947 8 AM to 5 PM weekdays.
Call our Health Services Department at 254.724.2111 after-hours, weekends and
When calling, have the following ready:
Our Health Services Department (HSD) staff provides a confirmation number for billing purposes to the
facility. This indicates that admission or observation has been called in within the authorized time frame.
This is not an authorization for payment. You'll be provided member benefits and approved
length-of-stay (LOS). The HSD Utilization Management Clinician may need to obtain a report from the
physician, utilization review or case management department of the facility prior to determining BSWHP
All elective and scheduled admissions for selected procedures must be pre-approved by BSWHP Medical
Director(s) through the appropriate BSWHP Authorization Form.
HSD reviews each hospitalization from the time of patient admission or observation through discharge and
follow-up care. Each hospitalization day must meet InterQual® and/or BSWHP internally developed criteria of
medical necessity, as determined by Plan Medical Director(s). The surgical patient must be admitted on the
day of surgery unless specific medical justification for earlier admission is provided and approved by the
Plan Medical Director(s). If we do not authorize an extension of hospital days based on submitted medical
justification, those days will not be paid.
It is noted that the majority of determinations made by BSWHP are related to benefit coverage interpretations according to the Evidence of Coverage (EOC) and/or Standard Plan Document (SPD) and do not involve issues of medical necessity or appropriateness. Other decisions about medical necessity or
appropriateness are made by the BSWHP Medical Director(s) with input from the treating clinical
Practitioners as appropriate. BSWHP benefit determinations are related to payment for care or services
based upon input from the Practitioner/Provider and according to the terms of the benefit contract.
HSD, delegated reviewers or BSWHP Medical Nurse Auditor(s) conduct Retrospective (Post-Service) reviews on cases not reviewed during the inpatient or concurrent review process. Cases may be missed due to the type or frequency of test or procedure when medical records were unavailable or the patient was admitted and discharged from a facility or provider's care before a report could be obtained or records reviewed (i.e., situations in which the case and/or medical records have never been reviewed by BSWHP due to circumstances beyond our control).
This does not include subsequent review of services for which prospective or concurrent reviews were previously conducted. When retrospective (Post-Service) review is performed, the review is based on written screening criteria (InterQual® or internally developed BSWHP Screening Criteria) established and annually updated with appropriate involvement from physicians (practicing physicians) and other healthcare providers. The HSD, delegated reviewer or Medical Nurse Auditor reviews any potential issues regarding medical necessity or appropriateness with the Plan Medical Directors(s). No medical necessity denials are issued without Medical Director review and approval. If any denial is issued, appeal rights are provided to both the Member and the Practitioner or Provider.
Some retrospective reviews may be conducted to collect data for health or medical care evaluation studies. These are not related to the payment of claims.
For information or clarification, contact our Health Services Department at 254.298.3088 or 888.316.7947.
BSWHP/BSWIC members are covered for life-threatening urgent and emergency care at any time in any facility. If any member requires observation or hospital admission, notify us as soon as possible post-stabilization, within 24-hours of admission to receive consideration of BSWHP coverage for the stay. If requesting inpatient level of care, include a summary of clinical presentation to support the request. An assigned BSWHP Utilization Review nurse reviews the request based on a combination of evidenced-based clinical guidelines, NCD/LCD and/or medical policy and responds to the admission request within 24-48 hours. If approved, concurrent review between the hospital case manager and the BSWHP Utilization Review nurse should occur during admission stay.
BSWHP/BSWIC provides a variety of benefit plans. Some lines of business (e.g. PPO/POS) have an out of network benefit. If the member stays in an out of network facility, the member may be responsible for the remainder of the bill regardless of the authorization. To minimize balance-billing costs, we encourage you to call us for assistance in transferring to an in-network facility.