Medical Provider Resources

Jump to Page Topics

• Medical Authorization Requests
• Medical Management Forms
• Continuity of Care Policy and Forms
• Medical Coverage Polices
• Medical Coverage Policies - Documents
• Reimbursement Policies
• Quality Improvement - Clinical Guidelines
• Clinical Programs
• Medical Management
  • Medical Authorizations
  • Medication Authorization
  • Care Coordination - Disease or Case Management
  • Care Guidance - Complex Case Management (CCM)
  • Disease Management
  • Utilization Management Program
  • Technology Assessment
• Pharmacy Services (links)
• Telemedicine
• Emergency Observation and — Services Provided by Out-of-Network or Non-contract Providers
• Hospitalization Procedures
• Provider Network Management Policies

Medical Authorization Requests

Prior authorization is required for the medical services, procedures and supplies listed in the respective list.

Prior Authorization Lists

• SWHP Consolidated Prior Authorization List
• SWHP Commercial Prior Authorization List
• SWHP (non-Medicare & non-Medicaid) Prior Authorization List
• BSWH Employees (non-Medicare & non-Medicaid) Prior Authorization List
• SWHP Cigna Prior Authorization List
• Medicare: SeniorCare Advantage HMO and SeniorCare Advantage PPO Prior Authorization List

For any item on the prior authorization list, be sure to complete a prior authorization request. The forms are based on the Texas Department of Insurance (TDI) Standardized Prior Authorization Form.

SWHP Prior Authorization Forms

Prior authorization requests for services and drugs obtained under the medical benefit (i.e. drug will be billed on a medical claim by a provider) are processed by SWHP Health Services Division.

Health Services Division does not process prior authorization requests for drugs obtained under the pharmacy benefit (i.e. prescription drug benefit). The submission process and forms below apply only to requests for medical benefit coverage of services and drugs.

For more information regarding prior authorization submission process for drugs obtained under the pharmacy benefit, visit the SWHP provider portal “Medication Authorization” section.

Health Services Division accepts medical benefit prior to authorization and peer-to-peer requests during regular business hours (8 a.m. to 5 p.m.) and any time after hours in the following ways:

• • Online: Log in to the secure Provider Portal to complete and submit the Prior Authorization form.
• • Fax: Download and complete the Prior Authorization form and cover sheet, then fax it to 1-800-626-3042.
• • Phone: For after-hours urgent admissions, or if online or fax submission is not possible, providers may call the Health Services Division directly: 1-254-298-3088 or 1-888-316-7947.

Annual PA Approval and Denial Rates

Statistics regarding Prior Authorization approval and denial rates for requested services.

• Diagnosis Label and Codes
• Service Type & Specialty

Each list includes statistics on:

• • Prior authorizations approved
• • Prior authorizations denied
• • Adverse determinations overturned on internal appeal
• • Total number of prior authorizations

Medical Management Forms

General

• Out-of-Network Referrals
• Outpatient Services Preauthorization
• Physician Referral Procedures
• Request for Designation as Secondary Care Physician

Special Circumstances

• Condition and Disease Guidance
• Cooperative Care
• Hospitalization Procedures
• Specialist as PCP Request
• Technology Assessment Form (downloadable Excel file)
• Termination Letter

Continuity of Care – Transition of Care Policy and Forms

• Continuity of Care—Transition of Care Form
• Continuity of Care—Transition of Care Form (Spanish)
• Continuity of Care—Transition of Care Policy

Medical Coverage Policies

Choose from the following policy topics below.

Medical Coverage Policies

Reimbursement Policies

Hospitalization Procedures

View policy documents

• SWHP ASO Policy
• SWHP Commercial Payment Policy
• Designation of Non-Primary Care Specialist as PCP Policy
• Member Confidentiality Policy
• Provider Claim Redetermination Policy
• Refusal of Treatment Policy
• Medicare Payment Policy
• Medical Policy and Prior Authorization Update Notices
• Medical Coverage Retired Policy Update Notice

Reimbursement Policies

We reimburse medically necessary surgical services. See the appropriate links below to download more information about specific policies.

• Bilateral and Multiple Surgical Procedures Policy
• Durable Medical Equipment (DME) Payment Policy
• Lessor of Reimbursement Payment Policy
• Modifier Payment Policy
• Never Events, Hospital Acquired Conditions (HAC), and Hospital Acquired Infections (HAI) Payment Policy
• Observation Reimbursement Policy
• View Readmissions within 30 Days Payment Policy
• Out-of-Network Facility-Based Policy

Quality Improvement: Clinical Guidelines

Clinical Guidelines

Clinical Programs

An effective approach to healthcare requires a clinical touch

In the face of escalating healthcare costs and rapid medical advancements, we’re continually evaluating and evolving our policies. We use clinical data, industry-accepted guidelines, and other sources to inform our quality measurement procedures.

We’re as equally committed to supporting transparency, which helps us, and our network of providers, make informed decisions regarding the healthcare of our members.

Read more about our clinical programs and review processes.

• Complex Case Management (CCM) — Simplifying the Management of Complex Cases
• Disease Management
• Utilization Management
• Technology Assessment
• Emergency Observation and Inpatient Services

Medical Management

Medical Authorizations

• Medical Authorizations

Medication Authorization

• Medication Prior Authorizations
• Medication Drug Lists (Formularies)

Care Coordination - Disease or Case Management

The philosophy of Scott and White Health Plan is to ensure that its members receive personalized, high-quality, cost-effective, comprehensive medical care. This health care should be consistently delivered by providers within the established Scott & White Hospital and Clinic system and/or through approved SWHP contracted providers.

In order to achieve our philosophical goals, the SWHP medical/nursing team utilizes the organized QA/UR plans to ensure members have access to high-quality medical care/treatment according to the provisions of their current SWHP benefit contract. Additionally, personalized case management by an assigned nurse Continuing Care Coordinator facilitates a comprehensive, multi-disciplinary approach to care pre-to-post hospitalization, which enhances the continuity of care and quality of life.

Care Guidance - Complex Case Management (CCM)

Simplifying the Management of Complex Cases

SWHP seeks to assist members who have experienced a critical event or diagnosis that requires extensive use of resources. Personalized case management by an assigned Complex Case Manager facilitates a comprehensive, multi-disciplinary approach to promote member autonomy and enhance the continuity of care and the member's quality of life. By combining advocacy with open communications and resource management, we're able to promote cost-effective care interventions and outcomes. Case managers help patients with chronic illnesses, catastrophic illnesses, or injuries get the most out of their healthcare.

Our program helps transfer patients to specialized treatment facilities, ensuring their care needs are met. Patients, with support from their physician and family members, set goals that roadmap their recovery to a healthier status. The scope of services provided include:

• • Initial health assessment status
• • Case Management program education
• • Member-specific care plan development
• • Care plan progress reassessments and evaluation of adherence
• • Regularly scheduled case manager contact, based on acuity
• • Transition of care support between inpatient to other facilities or home
• • Assistance in navigating and collaborating with providers and community resources

Participation is voluntary and there is no cost to our members.

To find out if Complex Case Management can benefit your patient, please call or fill out the Case Management Referral Form.

Disease Management

We believe in a better, healthier life for all. We work with members to help with their chronic illnesses or conditions through the development of a collaborative treatment plan with their primary care provider and ensure they are monitoring their conditions.

Our predictive modeling tool analyzes claims and pertinent data to:

• • Identify members with existing conditions
• • Establish current risk levels
• • Predict future risks

Members considered medium to high risk are assigned a dedicated health coach who helps identify personal goals and create a plan for self‐management. Through education, members are empowered to take control over the status of their health. For members in need of behavioral health services, our conditional guidance program identifies and addresses psychosocial issues. As they demonstrate a readiness to change, we guide members to make the behavior modifications necessary to achieve goals and improve health. Commercial members age 18+ qualify for ongoing guidance with:

• • Asthma
• • Chronic Back Pain
• • Chronic Kidney Disease
• • Chronic Obstructive Lung Disease (COPD)
• • Cognitive Impairment
• • Congestive Heart Failure
• • Coronary Artery Disease (CAD)
• • Crohn's Disease
• • Diabetes
• • Epilepsy/Seizures
• • HIV/AIDS
• • Hypertension
• • Migraines
• • Multiple Sclerosis (MS)
• • Obesity
• • Osteoarthritis
• • Parkinson's Disease
• • Post-Traumatic Stress
• • Rheumatoid Arthritis
• • Ulcerative Colitis

Utilization Management Program

• Technology Assessment Program
• Technology Assessment Form

Our Utilization Management (UM) Program ensures members receive services in a timely, appropriate, and cost-effective manner.

Utilization Management Program Description

The UM Program Description details the decision-making process we use across our Commercial, Self-Insured, and Medicare lines of business. The program is evaluated and updated annually by senior management, approved by the Quality Improvement Committee with recommendations from the Utilization Management Committee.

Pharmacy Services

• Formularies / Drug Lists
• Pharmacy Locations
• Drug Requests — Prior Authorizations, Exceptions & Appeals

Telemedicine

As a physician/health professional who practices in Texas, you have the opportunity to strengthen your provider/patient relationships by offering telemedicine services.

Telemedicine and telehealth services are covered for fully insured commercial PPO, EPO, and HMO/POS plans in accordance with Texas Insurance Code, Chapter 1455. Reimbursement is based upon rates for equivalent face-to-face services. Medical policies, benefits, and eligibility are also determining factors for reimbursement.

SWHP provides general reimbursement information and fee schedule information based upon coding. Click on the Provider Login link or Create an Account to view this information. You may also request it from your Provider Representative or by calling SWHP.

About Our Hospitalization Procedures for Members

We follow a review process for all emergency, elective, and scheduled hospital admissions.

Hospital Admission or Observation Status

Members are covered for life-threatening urgent and emergency care at any time in any facility. If any member requires observation or hospital admission, notify us within 24-48 hours of admission to receive consideration of SWHP coverage for the stay.

Call our Health Services Department at 1-254-298-3088 or 1-888-316-7947 Monday through Friday, 8 a.m. to 5 p.m.

Call our Health Services Department at 1-254-724-2111 after-hours, weekends, and holidays

When calling, have the following ready:

• • Member Name or membership number from SWHP Card
• • Day and time of admission or observation
• • Route of admission (ER, urgent, scheduled clinic admit)
• • Facility name and telephone number
• • Admitting or attending physician or provider
• • Telephone number for physician(s), or utilization review (U.R.) department
• • Admitting diagnosis
• • Scheduled or performed procedure(s)

Our Health Services Department (HSD) staff provides a confirmation number for billing purposes to the facility. This indicates that admission or observation has been called in within the authorized time frame. This is not an authorization for payment. You’ll be provided member benefits and approved length-of-stay (LOS). The HSD Utilization Management Clinician may need to obtain a report from the physician, utilization review, or case management department of the facility prior to determining SWHP coverage.

Pre-Admission Certification

All elective and scheduled admissions for selected procedures must be pre-approved by SWHP Medical Director(s) through the appropriate SWHP Authorization Form.

Concurrent and Continued Stay Review

HSD reviews each hospitalization from the time of patient admission or observation through discharge and follow-up care. Each hospitalization day must meet InterQual® and/or SWHP internally-developed criteria of medical necessity, as determined by Plan Medical Director(s). The surgical patient must be admitted on the day of surgery unless specific medical justification for earlier admission is provided and approved by the Plan Medical Director(s). If we do not authorize an extension of hospital days based on submitted medical justification, those days will not be paid.

Retrospective (Post-Service) Review

It is noted that the majority of determinations made by SWHP are related to benefit coverage interpretations according to the Evidence of Coverage (EOC) and/or Standard Plan Document (SPD) and do not involve issues of medical necessity or appropriateness. Other decisions about medical necessity or appropriateness are made by the SWHP Medical Director(s) with input from the treating clinical Practitioners as appropriate. SWHP benefit determinations are related to payment for care or services based upon input from the Practitioner/Provider and according to the terms of the benefit contract.

HSD, delegated reviewers, or SWHP Medical Nurse Auditor(s) conduct Retrospective (Post-Service) reviews on cases not reviewed during the inpatient or concurrent review process. Cases may be missed due to the type or frequency of test or procedure when medical records were unavailable or the patient was admitted and discharged from a facility or provider’s care before a report could be obtained or records reviewed (i.e., situations in which the case and/or medical records have never been reviewed by SWHP due to circumstances beyond our control).

This does not include subsequent review of services for which prospective or concurrent reviews were previously conducted. When retrospective (Post-Service) review is performed, the review is based on written screening criteria (InterQual® or internally-developed SWHP Screening Criteria) established and annually updated with appropriate involvement from physicians (practicing physicians) and other healthcare providers. The HSD, delegated reviewer, or Medical Nurse Auditor reviews any potential issues regarding medical necessity or appropriateness with the Plan Medical Directors(s). No medical necessity denials are issued without Medical Director review and approval. If any denial is issued, appeal rights are provided to both the Member and the Practitioner or Provider.

Some retrospective reviews may be conducted to collect data for health or medical care evaluation studies. These are not related to the payment of claims.

For information or clarification, contact our Health Services Department at 1-254-298-3088 or1-888-316-7947.

Emergency Observation and Inpatient Services

SWHP/ICSW Members are covered for life-threatening urgent and emergency care at any time in any facility. If any member requires observation or hospital admission, notify us as soon as possible post-stabilization, within 24-hours of admission to receive consideration of SWHP coverage for the stay. If requesting inpatient level of care, include a summary of clinical presentation to support the request. An assigned SWHP Utilization Review nurse reviews the request based on a combination of evidenced-based clinical guidelines, NCD/LCD and/or medical policy and responds to the admission request within 24-48 hours. If approved, concurrent review between the hospital case manager and the SWHP Utilization Review nurse should occur during admission stay.

Services Provided by Out-of-Network or Non-contract Providers

SWHP/ICSW provides a variety of benefit plans . Some lines of business (e.g. PPO/POS) have an out of network benefit. If the member stays in an out of network facility, the member may be responsible for the remainder of the bill regardless of the authorization. To minimize balance-billing costs, we encourage you to call us for assistance in transferring to an in-network facility.

Provider Network Management Policies

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