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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

SeniorCare (Cost) Medicare Plan — Provider Orientation

Medicare Advantage Plan — Provider Orientation

SWHP Provider Interactive Voice Response (IVR) System Guide

SWHP Provider Portal — Provider Training

Provider Webinar Training 2019

SWHP Brown Bag Webinar 11/3/2017

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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.

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 the member to get prior authorization for certain drugs. This means you’ll need to get approval from SWHP before prescriptions can be filled.

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 the member 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 call Customer Service 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 and 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 and 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 inclusive 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 drugs, the Health Plan requires a higher copayment or 100% copayment 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 copayment 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 and 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.

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