Provider Manual and Training
General provider resources
New to Baylor Scott & White Health Plan (BSWHP)? Review our orientation videos to learn about our operations, policies and procedures and helpful contact information. We also encourage established providers to review our orientations for refreshers and updates. We also provide a guide for our interactive voice response system.
Welcome to your guide for important provider information.
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Fraud, Waste & Abuse training for Providers and Pharmacists
The Centers for Medicare and Medicaid Services (CMS) requires all health plans offering Medicare Advantage - Prescription Drug plans ensure participating providers and pharmacists complete Fraud, Waste & Abuse (FWA) training on an annual basis.
If you are currently enrolled in the Medicare program or accredited as a Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS), we'll consider you as having met the training and educational requirements. To complete your training and for additional information, please visit The Medicare Learning Network®.
Pharmacist Fraud, Waste & Abuse training
All members of the pharmacy staff must complete the FWA Training. Only one attestation is required per pharmacy and it should be completed by the Head Pharmacist or Store Manager.
If you have already completed your training requirements through another mechanism, complete and submit the FWA Training Attestation.
If you have any questions or need assistance with this process, please contact our Compliance department at HPCompliance@BSWHealth.org or Customer Advocacy Department at 800.321.7947.
*See 42 CFR 422.503, 422.504, 423.504, 423.505 et seq.; see also Centers for Medicare and Medicaid Services, Prescription Drug Benefit Manual, Chapter 9 - Part D Program to Control Fraud, Waste and Abuse.
Policies and procedure library
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. To see how BSWHP Providers measured up, visit the link below.
Healthcare Effectiveness Data and 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 and scope of the QI program
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.
Questions? Our Customer Service and Provider Relations teams are here to help.
Provider rights and responsibilities
Baylor Scott & White Health Plan (BSWHP) contracted providers are responsible for providing and managing healthcare services for BSWHP members until services are no longer medically necessary.
Providers have the right to:
- Be treated courteously and respectfully by BSWHP staff at all times.
- Request information about BSWHP's utilization management, case management and disease guidance programs, services and staff qualifications and contractual relationships.
- Upon request, be provided with copies of evidence-based clinical practice guidelines and clinical decision support tools used by BSWHP.
- Be supported by BSWHP to make decisions interactively with members regarding their healthcare.
- Consult with BSWHP Medical Directors at any point in a member's participation in utilization management, case management or disease guidance programs.
- Provide input into the development of BSWHP's Case Management and Disease Guidance Programs.
- File a complaint on own behalf of a BSWHP member, without fear of retaliation and to have those complaints resolved.
- Receive a written decision regarding an application to participate with BSWHP within 90 days of providing the complete application.
- Communicate openly with patients about all diagnostic testing and treatment options.
- The right to appeal claims payment issues.
- The right to 90 days prior written notice of termination of the contract.
- The right to request a written reason for the termination, if one is not provided with the notice of termination.
Primary Care Physicians (PCPs):
- Provide primary healthcare services not requiring specialized care. (i.e., routine preventive health screening and physical examinations, routine immunizations, routine office visits for illnesses or injuries and medical management of chronic conditions not requiring a specialist)
- Obtain all required pre-authorizations as outlined in the Provider Manual.
- Refer BSWHP members to BSWHP contracted (in-network) specialists, facilities and ancillary providers when necessary.
- Assure BSWHP members understand the scope of specialty and/or ancillary services that have been authorized and how or where the member should access the care.
- Communicate a BSWHP member's medical condition, treatment plans and approved authorizations for services to appropriate specialists and other providers.
- Keep panel open to BSWHP members until it contains at least 100 BSWHP members on average per individual PCP.
- Will give BSWHP at least 7 days advance written notice of intent to close panel and may not close panel to BSWHP unless closing panel to all payors.
- Deliver all authorized medical healthcare services related to the BSWHP member's medical condition as it pertains to specialty.
- Deliver all medical healthcare services available to BSWHP members though self-referral benefits.
- Determine when the BSWHP member may require the services of other specialists or ancillary providers for further diagnosis or specialized treatment, as well as, if the member requires admission to a hospital, rehabilitation facility, skilled nursing facility or etc.
- Provide verbal or written consult reports to the BSWHP member's PCP for review and inclusion in the member's primary care medical record.
- Follow BSWHP's administrative policies and procedures and clinical guidelines when providing or managing healthcare services within the scope of a BSWHP member's benefit plan.
- Uphold all applicable responsibilities outlined in the BSWHP Member Rights & Responsibilities Statement.
- Maintain open communications with BSWHP members to discuss treatment needs and recommended alternatives, regardless of benefit limitations or BSWHP administrative policies and procedures.
- Provide timely transfer of BSWHP member medical records if a member selects a new primary care practitioner or if the practitioner's participation with BSWHP terminates.
- Participate in BSWHP Quality Improvement Programs, which are designed to identify opportunities for improving healthcare provided to BSWHP members and the related outcomes.
- Comply with all utilization management decisions rendered by BSWHP.
- Respond to BSWHP Provider Satisfaction Surveys.
- Provide BSWHP with any BSWHP member's written complaints or grievances against provider or practice immediately (within 24 hours). The process for resolving complaints should be posted in the provider's office or facility and should include the Texas Department of Insurance's toll-free number.
Providers should notify BSWHP when there are changes to their practice, such as:
- Change of ownership and tax identification number (TIN).
- Change of address (service/mailing/billing), phone number or fax number.
- New provider added to group or practice.
- Provider terminations from group or practice.
- Adverse actions impacting practitioner's ability to provide services.
- Termination from or opt out of participation in Medicare or Medicaid.
All changes reported should include an effective date.