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.
Provider Rights
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.
Provider Responsibilities
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.
Specialists
- 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.
All Providers
- 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.