Baylor Scott & White Health Plan (BSWHP) interoperability APIs are developer-friendly, standards-based, secure APIs that enable third-party application vendors to connect their application programs to access BSWHP data.

  • BSWHP interoperability API functionality
  • Developers portal

    The BSWHP Interoperability API Developer Portal provides third-party applications and payers access to documentation, registration services and developer services related to healthcare interoperability APIs provided by BSWHP, pursuant to the Centers for Medicare & Medicaid Services Interoperability and Patient Access Final Rule (CMS-9115-F). The patient access API will allow third-party applications to retrieve data, including but not limited to adjudicated claims, encounters and any clinical data maintained by BSWHP for both past and present members.

  • Privacy

    BSWHP appreciates that your medical information is personal and we are committed to helping you understand how to protect and secure your health information. Please review our privacy notice related to interoperability and the use of third-party applications.

Prior authorization metrics

For medical items and services (excluding drugs)

To comply with the CMS Interoperability and Prior Authorization final rule, Scott and White Health Plan d/b/a Baylor Scott & White Health Plan is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g. approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs and payers. For questions on the data below, contact us.

Prior to Jan. 1, 2026, impacted payers are required to send prior authorization decisions within the following timeframes:

  • For MA plans, and applicable integrated plans, 72 hours for expedited requests (urgent) and 14 calendar days for standard requests (non-urgent)
  • For CHIP FFS, 14 days for standard requests (non-urgent)
  • For Medicaid managed care plans and CHIP managed care entities, 72 hours for expedited requests (urgent) and 14 calendar days for standard requests (non-urgent)
  • For QHP issuers on the FFEs, 72 hours for expedited requests (urgent) and 15 days for standard requests (non-urgent)

There are no Medicaid FFS requirements regarding prior authorization decision timeframes for either type of request prior to Jan. 1, 2026, and there are no CHIP FFS requirements regarding prior authorization decision timeframes for expedited requests prior to Jan. 1, 2026.

Beginning Jan. 1, 2026, the CMS Interoperability and Prior Authorization final rule requires Medicare Advantage plans, state Medicaid agencies, Medicaid managed care plans, state CHIP agencies and CHIP managed care entities to send prior authorization decisions within:

  • 72 hours for expedited requests (urgent)
  • Seven calendar days for standard requests (non-urgent)

Reporting period: 2025

​​​​​​​​​​​​​

BSW SeniorCare Advantage HMO

Reporting level Number of occurrences Total requests Percentage
Non-urgent prior authorization requests*
Request approved 52,855 58,647 90.12%
Request approved after appeal 193 345 55.94%
Request approved after time extended 23 24 96%
Request denied 5,792 58,647 9.88%
Urgent prior authorization requests**
Request approved 2,898 3,240 89.44%
Request approved after appeal 22 46 47.83%
Request approved after time extended 0 0 ∅
Request denied 342 3,240 10.56%

*Response due to provider within 7 calendar days
**Response due to provider within 72 hours

Time elapsed between the submission of a request and a determination
Prior authorization request type Average time (in days) Median time (in days)
Non-urgent* 1.28 0.21
Urgent** 0.45 0.1

BSW SeniorCare Advantage PPO

Reporting level Number of occurrences Total requests Percentage
Non-urgent prior authorization requests*
Request approved 7,454 8,294 89.87%
Request approved after appeal 19 49 38.78%
Request approved after time extended 2 2 100%
Request denied 840 8,294 10.13%
Urgent prior authorization requests**
Request approved 449 500 89.8%
Request approved after appeal 5 8 62.5%
Request approved after time extended 0 0 ∅
Request denied 51 500 10.2%

*Response due to provider within 7 calendar days
**Response due to provider within 72 hours

Time elapsed between the submission of a request and a determination
Prior authorization request type Average time (in days) Median time (in days)
Non-urgent* 1.4 0.18
Urgent** 0.56 0.16

Marketplace (QHP)

Reporting level Number of occurrences Total requests Percentage
Non-urgent prior authorization requests*
Request approved 65,908 75,462 87.34%
Request approved after appeal 1,481 2,419 61.22%
Request approved after time extended N/A
Request denied 9,554 75,462 12.66%
Urgent prior authorization requests**
Request approved 3,798 4,443 85.48%
Request approved after appeal 68 125 54.4%
Request approved after time extended N/A
Request denied 645 4,443 14.52%

*Response due to provider within 7 calendar days
**Response due to provider within 72 hours

Time elapsed between the submission of a request and a determination
Prior authorization request type Average time (in days) Median time (in days)
Non-urgent* 0.68 0.005
Urgent** 0.8 0.5
X
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.
Confirm