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General Frequently Asked Questions for Providers

MyBenefits Frequently Asked Questions for Providers

If you can’t find your question answered below, contact Provider Relations at 1-800-321-7947.

How do I register for access to the Provider section of MyBenefits?

Answer

First, create an account. Fill in all required fields. After your request has been processed and authorized, you’ll be emailed a username and password.

If you are requesting claims access, please submit separate requests for each provider in your office that bills separately. If you’re only requesting member eligibility access, only one request is needed.

How do I check member eligibility or claim status?

Answer

  1. Go to Provider Access
  2. Select To register as a Provider click here
  3. Fill out all required fields under Provider Information
  4. Select Next
  5. Fill out all required fields under User Information
  6. In the User Preferences box, select what you need access for
    • Do you have authorization to view eligibility searches? Select "YES" or "NO"
    • Do you have authorization to view claims? Select "YES" or "NO"
  7. Press Submit
    • If your information is in our system, you’ll be prompted to log in to the site
    • If your Provider ID and Tax ID isn’t in our system, you’ll receive a message with a Request ID #. You’ll be notified by email when your request for access is approved. Please keep your Request ID # for future reference

How do I log into the Provider portal?

Answer

  1. Go to Provider Access
  2. Enter your Username
  3. Enter your Password
  4. Press Enter

How do I log in to the portal when I don’t know the password?

Answer

To reset your password, go to our Request Password page

  1. Fill in the required fields, then press Next
  2. A new password will be sent to the email address we have on file for you (If you don’t see an email from us, be sure to check your spam folder)
  3. Log in to Provider Access

Why am I locked out of my account?

Answer

If you have been locked out, it’s usually because you had too many unsuccessful login attempts. To unlock your account:

Include your name, tax ID number, NPI number, username, and phone number in your email.

How do I find out a Member’s eligibility?

Answer

  1. Select Member Eligibility from the Members tab and the Members Eligibility Inquiry page will display
  2. Enter the Member’s Date of Birth and Last Name in the Search Section
  3. Press Search to retrieve the results
  4. Press Cancel to return to the Provider homepage

How do I check the status of a claim?

Answer

  1. Select Claims Status Search from the Claims tab and the Claims Status Inquiry page will display
  2. Enter the required information in the Patient/Subscriber Information section
  3. Press Search to display the Explanation of Payment (EOP) List page
  4. Press the Claim Number link to see its Claims Status Response page. If you cannot find a specific claim, it may be because:
    1. We haven’t received the claim
    2. There may be an issue with the claims clearinghouse
    3. The claim is billed with a provider number/NPI number that you don’t have clearance to view
    4. The claims clearinghouse did not send the claim to us
  5. Press Cancel to return to the Provider homepage

I can’t find a Member’s Summary of Benefits (SOB).

Answer

If you can’t find the Summary of Benefits (SOB) PDF through the site, please call our Provider Relations Department at 1-800-321-7947 and with your group name and group number.

I can’t view an eligible Member’s history.

Answer

Enter the member’s appointment date or any previous date to verify the actual date the member became eligible with us. The member number is specific to the group or individual plan the member is enrolled in.

You can also try to perform a name search using the member’s first and last name under the Member No. box to see if the member was enrolled in another group or individual plan.

Which procedures require a preauthorization from SWHP?

Answer

Log in to the provider section of MyBenefits for a listing of preauthorization requirements by line of business. Services, procedures, drugs, and durable medical equipment that require preauthorization must be medically necessary and meet SWHP coverage criteria.

A prior authorization is needed if you plan to refer a member out of the SWHP network. Visit our Medications page to learn more or call our pharmacy help desk at 1-800-728-7947.

Frequently Asked Questions for Pharmacists

If you can’t find your question answered below, contact our Pharmacy Help Desk at 1-800-728-7947 for more assistance.

What are your pharmaceutical management procedures?

Answer

Our procedures describe the method for managing the drug formulary to provide the most cost-effective therapy options.

Prior Authorization: We may require you or your physician to get prior authorization for certain drugs. This means you’ll need to get approval from SWHP before you fill your prescriptions.

Quantity Limits: For certain drugs, we limit the amount of the drug that SWHP will cover. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, we require your customer to try certain drugs first to treat the medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, SWHP may not cover Drug B unless you try Drug A first. If Drug A does not work, we’ll then cover Drug B.

There may be copayments on prescriptions:

A = A tier generic copay (preferred generic)
B = B tier preferred brand copay
C = C tier non-preferred copay

Drugs not on the formulary may be covered at a non-formulary copay if:

  1. The drug is medically necessary
  2. The plan rules are followed
  3. The drug is not considered an excluded drug

Excluded drugs are not covered by SWHP. For example, a drug used for cosmetic purposes may be considered an excluded drug. Please review an Evidence of Coverage (EOC) document and other plan materials to determine which drugs are excluded from coverage.

Review our drug listings or by calling Customer Advocacy at 1-800-321-7947 to find out if a drug has additional requirements or limits.

How was the prescription drug formulary developed and officially sanctioned by SWHP?

Answer

Our formulary is developed, officially sanctioned, and approved by the Pharmacy and Therapeutics Committee (P&T) of the Scott & White medical staff. The P&T Committee reviews for inclusion based on safety, effectiveness, overall cost of the drug therapy.

Why is a formulary necessary within a Health Maintenance Organization (HMO) structure?

Answer

A formulary is necessary for the HMO to establish a reasonable, evidence-based approach to drug therapy that ensures quality and cost-effectiveness for the member and Scott & White Health Plan. We’re responsible for the prescription drug costs of about two-thirds of our members. The formulary is one method for controlling such costs while assuring quality of care. To remain competitive with other managed care entities with formularies, it is essential we are able to control prescription drug costs for our members in a similar fashion.

How is a drug added to the SWHP Formulary?

Answer

The P&T Committee will consider a drug for addition to or deletion from the formulary when a Formulary Request Form is received from the requesting physician. A drug will not be added to the formulary unless it offers significant additional evidence-based clinical or financial benefits.

How are costs more effectively controlled using a formulary?

Answer

First, quality issues are clearly answered. Then, the pharmacy can approach the manufacturers for best contract pricing based on being inclusion of the formulary and/or given preferred status within a given therapeutic category. This allows us to leverage our volume of business within the marketplace to achieve best prices for our membership—without jeopardizing quality. In fact, this approach provides a framework for quality assurance of drug therapy based on the in-depth clinical study and analysis done by the pharmacy and medical staff within each drug therapy category.

An effective cost-containment approach is selecting a preferred therapeutic agent within a drug class. The preferred agent (sometimes more than one) in a category is chosen based on efficacy, safety, and the therapeutic benefit/cost ratio. The preferred agent should be prescribed for all new starts and all changes of medications within a drug category.

What is the therapeutic interchange policy?

Answer

Our Pharmacy and Therapeutics Committee (P&T) evaluates clinical equivalence as a part of the drug review and makes recommendations regarding interchanging drugs within a therapeutic category. The Therapeutic Interchange Policy states that physicians must approve in writing the therapeutic drug interchange. View the Medications page for more information and our online request form.

How does the SWHP Formulary differ from many other managed care approaches to formulary?

Answer

Unlike many other plans, our medical staff, practitioners, and specialists evaluate clinical data and varied approaches to drug therapy before granting a drug inclusion in the formulary. A drug is deemed appropriate for inclusion after safety and effectiveness have been sanctioned by our experts. After all clinical and efficacy questions have been answered and quality is sanctioned, competitive costs are evaluated and final inclusion is approved or rejected.

We’ve successfully used this approach to formulary for over a decade.

What does the formulary mean for our members?

Answer

Although we hope the medical staff uses the same formulary approach for all members, the formulary contractually only applies to members with the Prescription Drug Benefit Rider. We can only mandate specific coverage when we are at risk or have a contract that includes those services.

The formulary guides prescription coverage for all SWHP patients. Please refer to this formulary when prescribing for your SWHP patients. The formulary is not a substitute for the professional and clinical judgment of the physician.

For those members with the Prescription Drug Benefit Rider, the Health Plan will only provide full coverage for drugs included on the formulary or preferred within a given category. For drugs not on the formulary or non-preferred, the Health Plan requires a higher co-payment or 100% co-payment from the member.

What if I write a prescription for a non-formulary medication?

Answer

We will contact the prescribing physician and advise of the available formulary medications in that therapeutic category. If the physician indicates the non-formulary drug is needed, the patient will pay the higher co-payment or full charge of the prescription, as required by their plan.

We have determined that the following medications will not be covered by the drug benefit:

  • Over-the-counter drugs
  • Appetite suppressants
  • Drugs used for infertility
  • Drugs used for cosmetic purposes

What if a medication requires prior authorization?

Answer

Submit a completed Prior Authorization Request for Individual Case Review (ICR) to Scott & White Prescription Services. You can also find this form in your copy of the Spotlight Notebook or by contacting Prescription Services at 1-800-728-7947.