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Important 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.

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.

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

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.

  • 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.

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.

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).

  • Health Talk: View this month's featured areas of our health talk:
    • COPD: Learn more about ways to manage your COPD including options to quit smoking.
    • Heart Health: February is American Heart Month, which is a great reminder for your patients to focus on a healthy heart. View the Heart Health flyer that can be distributed to your patients.
  • 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.

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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.

Supporting Clinical Documentation

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