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Orientation Training

Helpful orientation and education resources for our providers

New to SWHP? Review our orientation videos to learn about our operations, policies, and procedures, and helpful contact information. We also encourage established providers to review our orientations for refreshers and updates. We also provide a guide for our interactive voice response system

Commercial HMO/PPO Plans — Provider Orientation

Medicare Advantage Plan — Provider Orientation

SWHP Provider Interactive Voice Response (IVR) System Guide

SWHP Provider Portal — Provider Training

Provider Webinar Training 2019

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Provider Manual

Welcome to your guide for important provider information.

Download and view our Provider Manual.

Or, quickly find what you're looking for from the topics below.

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Fraud, Waste & Abuse Training for Providers and Pharmacists

The Centers for Medicare and Medicaid Services (CMS) requires all health plans offering Medicare Advantage – Prescription Drug plans ensure participating providers and pharmacists complete Fraud, Waste & Abuse Training annually.* This training must be completed by December 31st of each year.

If you're a First Tier, Downstream, or Related Entity (FDR) currently enrolled in the Medicare program or accredited as a Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS), we'll consider you as having met the training and educational requirements for fraud, waste & abuse. For additional information, refer to the CMS regulation document. If you have any questions or need assistance with this process, please contact our Compliance Manager at SWHPComplianceDepartment@bswhealth.org or Customer Advocacy Department at 1-800-321-7947.

Pharmacist Fraud, Waste & Abuse Training

All members of the pharmacy staff must complete the Fraud, Waste & Abuse Training. Click here to begin your training online.

Only one FWA Training Attestation Form is required per pharmacy, and it should be completed by the Head Pharmacist or Store Manager.

Provider Fraud, Waste & Abuse Training

If you're a provider, click here to begin your training online.

If you have already completed your training requirements through another mechanism, complete and submit the FWA Training Attestation Form.

*See 42 CFR 422.503, 422.504, 423.504, 423.505 et seq.; see also Centers for Medicare and Medicaid Services, Prescription Drug Benefit Manual, Chapter 9 - Part D Program to Control Fraud, Waste and Abuse.

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Quality Improvement

National Committee for Quality Assurance (NCQA) Accreditation

NCQA Accreditation is a comprehensive evaluation of health plans clinical measures and consumer experience measures. Standards are developed with the help of health plans, providers, insurance customers, unions, regulatory agencies and consumer groups. NCQA's Health Plan Accreditation is considered the industry's gold standard. NCQA Accreditation measures five areas of performance: Staying Healthy, Getting Better, Living with Illness, Access and Service, and Qualified Providers. To see how SWHP Providers measured up, click the link below, then choose "Health Plan Report Card" and search for "Scott and White" to see our ratings.

Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS® is a registered trademark of NCQA. SWHP uses HEDIS® to measure clinical quality performance and evaluate areas of care: preventive services, treatment of acute illness, management of chronic illnesses, and patient experience with services provided (as measured through the CAHPS, a standardized survey used by all plans).

Accessibility to Healthcare Services

Purpose and Scope of the QI Program

The purpose of the quality improvement program is to ensure SWHP is providing the highest quality care that is easy to access and affordable to our members regardless of plan type, age, race/ethnicity or health status. SWHP supports and tries to reach "Triple Aim" goals: improving Member's affordability, quality and experience of care. SWHP Quality programs and improvement projects are designed to improve member outcomes through systematic ongoing measurement, provider/member/health plan care coordination, and continuous evaluation of results.

The scope of the QI Program is to monitor, evaluate and improve:

  • • The quality and safety of clinical care
  • • The quality of service provided by SWHP
  • • The quality of practitioners and providers
  • • Affordable and accessible health care and wellness
  • • The overall Member experience

SWHP strives for personal differentiation. No matter the product, the Member is our focus. SWHP has many examples of helping our members navigate the maze of healthcare, as well as thoughtful interventions that have improved the health outcomes of our Members. SWHP's close connection to both our Members and our provider community places us in a unique position to act as an effective member advocate. As a regional health plan, we have exceptional opportunities to finance health care in a way that is intrinsically superior by aligning incentives, identifying gaps in health care delivery, and facilitating smooth and seamless coordination of care throughout the health care continuum.

QI Program Goals - Objectives

  1. Improve Member Health Outcomes - through staying healthy and management of chronic conditions such as the following: Diabetes, Asthma, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Behavioral/Mental Health, Children's' and Women's' Health

  2. Improve Medical Safety - by fostering a supportive environment that helps providers to improve the safety of their practice, monitoring SWHP Pharmacy medication safety, monitoring medication errors, and providing Members with information that improves their knowledge about clinical safety in their own care.

  3. Increase Member Satisfaction - by prompt identification and resolution of dissatisfaction with administrative or medical processes. Evaluate processes for improvement. SWHP conducts the CAHPS survey to measure Member Satisfaction annually. This survey is use to identify opportunities for improvement.

  4. Meet the Cultural and Linguistic Needs of the Member – by identifying language and other cultural/social needs of SWHP Members. We meet those needs by providing bilingual services, translated materials, cultural diversity education, training for SWHP staff and a network of diverse and multilingual providers. SWHP regularly monitors Member demographic data and Member feedback to adjust the provider network and services to reflect the Member's needs.

  5. Provide Affordable Care - through reducing the variations in clinical care, preventing overuse, underuse or misuse of services, redirection of care to the most appropriate place, and through continued improvement of all SWHP processes to optimize care and reduce unnecessary care.

  6. Organizational Effectiveness – strive to achieve statistically significant improvements in all quality measurements to meet or exceed regional or national averages set forth by National Committee Quality Assurance, Centers for Medicare and Medicaid (CMS), Texas Department of Insurance (TDI) and Texas Health and Human Services Commission (HHSC) or other accepted quality Standards.

  7. Additional Documents

    Physician Office Visit Information Form

    Clinical Guidelines

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Provider Rights and Responsibilities

Scott and White Health Plan (SWHP) contracted providers are responsible for providing and managing health care services for SWHP members until services are no longer medically necessary.

Provider Rights

Providers have the right to:
  • • Be treated courteously and respectfully by SWHP staff at all times.
  • • Request information about SWHP'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 SWHP.
  • • Be supported by SWHP to make decisions interactively with members regarding their health care.
  • • Consult with SWHP 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 SWHP's Case Management and Disease Guidance Programs.
  • • File a complaint on own behalf of a SWHP member, without fear of retaliation, and to have those complaints resolved.
  • • Receive a written decision regarding an application to participate with SWHP 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 health care 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 SWHP members to SWHP contracted (in-network) specialists, facilities, and ancillary providers when necessary.
  • • Assure SWHP 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 SWHP member's medical condition, treatment plans, and approved authorizations for services to appropriate specialists and other providers.
  • • Keep panel open to SWHP members until it contains at least 100 SWHP members on average per individual PCP.
  • • Will give SWHP at least 7 days advance written notice of intent to close panel and may not close panel to SWHP unless closing panel to all payors.
Specialists:
  • • Deliver all authorized medical health care services related to the SWHP member's medical condition as it pertains to specialty.
  • • Deliver all medical health care services available to SWHP members though self-referral benefits.
  • • Determine when the SWHP 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 SWHP member's PCP for review and inclusion in the member's primary care medical record.
All Providers:
  • • Follow SWHP's administrative policies and procedures and clinical guidelines when providing or managing health care services within the scope of a SWHP member's benefit plan.
  • • Uphold all applicable responsibilities outlined in the SWHP Member Rights & Responsibilities Statement.
  • • Maintain open communications with SWHP members to discuss treatment needs and recommended alternatives, regardless of benefit limitations or SWHP administrative policies and procedures.
  • • Provide timely transfer of SWHP member medical records if a member selects a new primary care practitioner, or if the practitioner's participation with SWHP terminates.
  • • Participate in SWHP Quality Improvement Programs, which are designed to identify opportunities for improving health care provided to SWHP members and the related outcomes.
  • • Comply with all utilization management decisions rendered by SWHP.
  • • Respond to SWHP Provider Satisfaction Surveys.
  • • Provide SWHP with any SWHP 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 SWHP 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.

This page updated August 4,2014

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Telemedicine

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Frequently Asked Questions for Providers

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

Provider Portal Training Guide

How do I register for access?

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.

Also, you may refer to the Provider Portal Training Guide.

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 Portal

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 provide the 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.

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Frequently Asked Questions on Pharmacy Services

If you can't find your question answered below, contact the Pharmacy Help Desk for assistance. Pharmacy Help Desk information is located at: https://swhp.org/en-us/prov/contact-us.

What are your pharmaceutical management procedures?

Answer

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

Prior Authorization: We may require prior authorization for certain drugs. This means approval may be needed before prescriptions can be filled.

Quantity Limits: For safety and cost reasons, certain drugs have limits on the amount of the drug that SWHP will cover at one time. This is often based on the manufacturer’s recommended dosages and may be in addition to a standard one-month or three-month supply.

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

The formularies include drugs that are covered under the prescription benefit. The formularies are tiered, meaning there are different copayments for different drugs dependent upon cost and place in therapy.

Drugs not on the formulary may be covered 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 call the Pharmacy Help Desk to find out if a drug has additional requirements or limits. The Pharmacy Help Desk information is located at: https://swhp.org/en-us/prov/contact-us.

What is a prescription drug formulary, and how are they developed?

Answer

Formularies are a list of covered drugs required for a quality treatment program. Formularies are developed by a Pharmacy and Therapeutics Committee (P&T). The P&T Committee reviews drugs for inclusion based on safety and effectiveness. Once safety, effectiveness, and place in therapy are evaluated, then overall cost of the drug therapy is considered.

How is a drug added to a Formulary?

Answer

The P&T Committee evaluates new drugs as they become available and routinely conducts therapeutic drug class reviews to determine the most cost-effective therapy options for inclusion in the formulary. Providers can also submit formulary addition requests for P&T Committee consideration. 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

Formularies are developed by a P & T Committee that evaluates the safety and efficacy of drugs within each therapeutic category.

An effective cost-containment approach is selecting the preferred therapeutic agent(s) within each drug class. The preferred agent(s) in a category are chosen based on efficacy, safety, and the therapeutic benefit/cost ratio. Prescribing preferred agents help ensure cost effective therapy for the member and the Health Plan.

What do the formularies mean for our members?

Answer

The formularies guide prescription drug coverage for patients with SWHP prescription drug benefits. Please refer to the formularies when prescribing for your SWHP patients. The formularies are not a substitute for the professional and clinical judgment of the prescriber.

For those members with a SWHP Prescription Drug Benefit Rider, the Health Plan will provide coverage for drugs included on the formularies in accordance with plan rules and other utilization management restrictions.

Drugs not on the formulary may be covered if:

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

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

Answer

Non-formulary drugs typically require prior authorization for consideration of coverage. In order for the drug to be covered by the plan, the provider must provide clinical justification as to why formulary alternatives are not appropriate for the member.

Excluded drugs are not covered by SWHP. Please review an Evidence of Coverage (EOC) document and other plan materials to determine which drugs are excluded from coverage.

What if a medication requires prior authorization?

Answer

Visit this link for information regarding prior authorizations https://swhp.org/prov/pharmacy-resources#prov-medication-authorization.

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