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For ProvidersClaims and Billing

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IMPORTANT NOTICE: Claim refunds must always be sent to the claims refund address.

Any claim refunds sent to the paper claims address will be returned to the sender for correction.

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New Prior Authorization Requirements — Evicore

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How to File a Redetermination

If your claim was denied or you're unhappy with your reimbursement, you may be able to have your claim reprocessed. Currently, we allow redeterminations to be filed for claims based on:

  • • Filing limits
  • • Claim check or code editing
  • • Contracted rate or payment policy
  • • Coordination of Benefits (COB)
  • • Data entry error
  • • Overpayment or underpayment

To file a redetermination , you must:

If there are multiple claims in question, you may provide an Excel spreadsheet that contains the additional information. Attach spreadsheet to a copy of the request form.

Mail your redetermination or request for adjustment to:

  • Scott and White Health Plan
  • ATTN: Claims Review Dept.
  • P.O. Box 21800
  • Eagan, MN 55121-0800

The provider redetermination time limit for receipt of redetermination request is calculated from the date of original denial or Explanation of Payment (EOP). The Provider Claim Retedermination Request Form is processed within 30 days of receipt. To appeal RightCare Medicaid claims, visit RightCare.

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How to Submit a Claim

Whether you’re filing electronic or paper claims, to avoid having claims delayed, denied, or sent back to you for corrections, you’ll need to:

  • • Meet filing deadlines
  • • Submit clean claims

Filing Deadline

All claims must be received in our office within 95 days of the date of service, or they will be denied. Coordination of Benefit (COB) claims must be submitted within 95 days of the primary payer's Explanation of Benefits (EOP) date.

For paper claims, the claims receipt date is when your claim reaches our mailroom. Claims received after 2 p.m. will be considered received the next business day. Please note that members cannot be billed for claims denied by SWHP for missing filing deadline.

    Clean Claims

    These are claims that we will accept without having to investigate or send back for more information. Clean electronic and paper claims should have:

    • • Patient's full name
    • • Patient's date of birth
    • • Valid SWHP member identification number (11-digit number)
    • • Complete service level information
      • • Date of Service
      • • Industry-standard diagnosis codes
      • • CMS defined industry-standard place of service codes
      • • Industry-standard procedure codes (e.g., CPT, HCPCs)
      • • Charge information and units
    • • Service provider's name, address, and National Provider Identification (NPI)
    • • Provider's federal tax identification number (TIN)
    • • Only one servicing provider per claim
    • • All claim forms must be typed; no handwritten information or corrections
    • • All required fields completed

    For paper claims, we use an imaging system for claims entry. Follow these guidelines to ensure your claim is processed accurately, and without delay or rejection. Do not send:

    • • A fax or a copy of a filled-out form
    • • A claim that's been torn, taped, or crumpled
    • • A claim that's been stamped or handwritten on

    Do not use:

    • • Correction fluid or tape
    • • Ink that is fading, and/or a color other than black
    • • Staples
    • • Highlighters

    Claims that are rejected for any of the above listed reasons will be returned to you with a letter explaining the reason for the rejection. These non-clean claims are considered never received and must be corrected and resubmitted within the SWHP claims filing deadline for reconsideration.

    Claim Tutorials

    Watch the following tutorials to learn how to correctly fill in the required fields.

    Reimbursement

    We reimburse medically necessary surgical services and other procedures. For more information, see procedure-specific payment policies.

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    How to File Electronic Claims

    Filing claims has never been faster

    Faster responses mean everything in the healthcare industry, so let's reduce the time it takes to process your claims. By filing electronic claims, you can expect:

    • • More timely payments
    • • Faster claim status responses
    • • Lower overhead costs
    • • More control over claim data accuracy

    You may also submit claims through the HIPAA-compliant Availity Web Portal.

    About Availity

    Availity offers a secure web portal that is simple to use, integrating with software systems typically found in most physician’s offices and hospitals around Texas. Availity also delivers information beyond what is available in standard HIPAA transactions.

    • • Providers submit batch claims for free
    • • Medical software vendors may charge a fee for installation and maintenance of system enhancements that support claims transmissions
    • • You must use your National Provider identifier (NPI) number when submitting claims through Availity so proper provider identification can be made
    • • When submitting claims, use the Scott and White Health Plan Payer Number 88030
    • • Both UB-04 and CMS 1500 claim forms are accepted electronically
    • • You are strongly advised to review your accepted/rejected reports from Availity daily to determine if any claims were rejected by SWHP
    • • Patients' Member Identification Numbers must be complete (and include the two-digit suffix) for a claim to be accepted electronically

    Non-contracted providers must fill out an EDI Intake Form before filing claims to SWHP for the first time. The EDI Intake Form is for our Configuration team to enter your provider information into our claims adjudication system.

    For more information, visit Availity or call them at 1-800-282-4548.

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    How to File Paper Claims

    If you prefer to file claims the old-fashioned way, we do accept paper claims. This will take longer to process than electronic claims. You’re expected to follow Texas Department of Insurance (TDI) requirements, as well as meet our requirements for filing claims.

    To avoid having your claims delayed, sent back, or denied, please be sure to review our submission guidelines and tutorials and send your correspondence, by type, either to the Paper Claims Address or to the Claim Refunds Address posted below, as appropriate.

      For your convenience, we provide the following forms:

      Paper Claims Address

      • Scott and White Health Plan
      • ATTN: Claims Review Dept.
      • PO Box 21800
      • Eagan, MN 55121-0800

      Claim Refunds Address

      • Scott and White Health Plan
      • ATTN: Claim Refunds
      • PO Box 840523
      • Dallas, TX 75284-0523

      Certified Mail Address

      • Scott and White Health Plan
      • c/o Smart Data Solutions
      • 960 Blue Gentian Road
      • Eagan, MN 55121-1500

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      How to File Medicare Claims

      Submitting Medicare claims

      We have a contractual arrangement with the Centers for Medicare & Medicaid Services (CMS) to provide SeniorCare Advantage HMO and SeniorCare Advantage PPO Medicare Plans. The following applies to our SeniorCare (Cost) plans only.

      Part A Services

      All claims billed on UB-04 for Part A services should be filed with Medicare Part A. We do accept crossover claims from Medicare. If you bill secondary claims to us for Medicare primary claims, we are now receiving daily electronic files from Medicare, and will be processing provider payments from these electronic Medicare submissions.

        Part B Services

        We act as the Medicare intermediary for some Part B services for SeniorCare members only. Please refer to your contract for further details.

        Exceptions

        CPT codes 90801–90899 for psychiatric services and 90918–90999 for dialysis should be filed directly with CMS.

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        Coordination of Benefits

        Who pays first when there’s duplicate coverage?

        When your patient has more than one insurance provider, we follow Coordination of Benefits (COB) standards to determine if we’re the primary or secondary payer. These are standards set by the National Association of Insurance Commissioners (NAIC).

        We coordinate benefits payable for covered services with benefits payable by other plans, consistent with state law. Claims submitted to SWHP for secondary payment must include the primary carrier’s Explanation of Benefits (EOB).

        Please note that if we’re reimbursing services as a secondary carrier, our policies and procedures regarding referral, prior authorization, and prior approval must still be followed.

        If you have any COB questions, or need clarification on how to coordinate benefits, give us a call.

        Medicare Coordination of Benefits Guidelines

        If member is covered by Medicare and is: Primary Secondary
        • • Age 65 or over
        • • An actively working subscriber
        • • Employer group with 20 or more employees
        Scott and White Health Plan Medicare
        • • Age 65 or over
        • • An actively working subscriber is actively working
        • • Employer group with fewer than 20 employees
        Medicare Scott and White Health Plan
        • • Age 65 or over
        • • A retired subscriber
        Medicare (as of retirement date) Scott and White Health Plan
        • • Age 65 or over
        • • On Medicare due to disability
        • • An actively working subscriber
        • • Employer group with 100 or more employees
        Scott and White Health Plan Medicare
        • • Age 65 or over
        • • On Medicare due to disability
        • • An actively working subscriber
        • • Employer group with fewer than 100 employees
        Medicare Scott and White Health Plan
        • • Age 65 or over
        • • A subscriber not actively working
        Medicare Scott and White Health Plan

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        Workers' Compensation (Third-Party Liability)

        When a patient is injured on the job — whether in-office or off-site — we want to help get them back to work. All workers' compensation claims should be filed directly with us.

        Subrogation

        Sometimes, your patient's employer or a third party may be financially responsible for work-related medical services for an accident or injury that we’ve already covered. This is known as subrogation. In this case, we have the right to be reimbursed for these medical services.

        If your office becomes aware of a possible subrogation claim, complete the accident form. Then contact The Bratton Firm via one of three ways:

        • • Call 1-800-741-4926
        • • Fax accident form to 1-512-477-6081
        • • Mail accident form to:
          • The Bratton Firm
          • 1100B Guadalupe Street
          • Austin TX, 78701

        Your patients may also contact The Bratton Firm to learn more as well.

        For additional information on any subrogation claim, contact Customer Advocacy at 1-800-321-7947.

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        Account Reconciliation

        A mistake was made — let's reconcile

        Even when claims are properly documented, there's always the chance of error. We work hard to identify and resolve accounting issues so correct payments can be made.

        Retractions & Recoupments

        Retractions and recoupments are made for various reasons, including:

        • • Duplicate payment on a procedure
        • • Incorrect payment on a procedure
        • • Payment to the wrong provider

        To make a retraction or a recoupment, you'll need to file an appeal.

        Returned Checks

        If you return a Scott and White Health Plan check for an adjustment, attach the following documents:

        • • An explanation for the adjustment
        • • A copy of the EOP
        • • Copies of prior payments
        • • Any other documentation explaining the payment discrepancy

        Send returned or misdirected (sent to the wrong payee) checks to:

        • Scott and White Health Plan
        • Attn: Voids and Refunds ‐ Claims
        • 1206 West Campus Drive
        • Temple, TX 76502

        Refund Checks

        For all SWHP member claims, providers should send refund checks to reimburse money owed to Scott and White Health Plan to:

        • Scott and White Health Plan
        • Attn: Claims Department
        • PO Box 840523
        • Dallas, TX 75284-0523

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        Locum Tenens Billing

        We'll cover you when someone else is covering for you

        Maybe you're going on vacation. Perhaps a clinician is ill. As a network provider, you may have locum tenens physicians and clinicians temporarily working in your office from time to time.

        In these cases, it will be your responsibility to:

        • • Contact us to let us know who the locum tenens physician is, and how long they'll be providing services
        • • Provide oversight of the locum tenens physician as it relates to services that can be performed and authorization/pre‐certification requirements
        • • Provide reimbursement to the locum tenens physician

        Services performed by the locum tenens physician should be billed to us under the provider name and number of the network physician who is providing oversight.

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        Statutory Verification

        Senate Bill 418, enacted by the Texas Legislature, allows our contracted providers to verify payment of a claim for a member. Known as statutory verification, this serves as a guarantee of payment, if granted.

        Declination

        Declination is the refusal to give statutory verification. This does not equate with claim denial or adverse determination. It simply means we are unable to guarantee payment based upon the information we have at the time of the declination. We'll let you know the reason if we issue a declination.

        Requirements

        When requesting a statutory verification, you’ll need to provide:

        • • Name of provider
        • • Provider's federal tax ID number
        • • Patient name
        • • Patient SWHP ID number
        • • Patient date of birth
        • • Patient relationship with enrollee
        • • Presumptive diagnosis, if known; otherwise, presenting symptoms
        • • Description of proposed procedure or procedure codes
        • • Place of service code where services will be provided; if other than provider's office, name of hospital or facility where proposed service will be provided
        • • Proposed date of service
        • • Group number
        • • Name and contact of any other carrier, if known to provider

        To request a statutory verification, contact us and provide the state mandated required elements. For a routine care statutory verification, we will will respond within five days.

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