skip to main content

Enter Title

Medical Resources

Text/HTML

Text/HTML

Provider Section Home and News Pharmacy Resources Medical Resources Provider Claims and Billing Provider Manual and Training Provider Account Management Provider Complaints and Appeals Contact Us
For ProvidersMedical Resources

Text/HTML

IMPORTANT NOTICES

Retroactive Authorization Requests

Effective June 1, 2017, the SWHP Health Services Department (HSD) no longer accepts retroactive authorization requests. If a service requires prior authorization and the authorization is not obtained prior to the service being rendered, the claim for the service will be denied.

The SWHP HSD will continue to accept retroactive notifications for the limited services that require one. A reference number will be provided for the notification. For more information, please do not hesitate to contact the SWHP HSD at 1-888-316-7947.

For BSWH Employee Plan ONLY.

All SWHP non-contracted provider requests for prior authorization are processed by Cigna.

Please take the following steps to ensure your request is processed in a timely manner:

  • You MUST FIRST verify benefits and eligibility with SWHP by phone. Call 1-844-769-3994 and speak to a customer advocate.
  • When verification is complete, you may have the advocate transfer you directly to Cigna, OR you may contact Cigna at 1-866-494-4872 to determine prior authorization requirements and initiate prior authorization requests.

Text/HTML

New Prior Authorization Requirements — Evicore

Text/HTML

Log In to Your Provider Account

View member information. Track claims. Get marketing materials and more.

Create an Account

Text/HTML

Medical Authorization Requests

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

Prior Authorization Lists

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

Health Services Division accepts prior 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.

Text/HTML

Medical Coverage Policies

Last Revised

Next Review Date

Acupuncture 01/25/2018 01/25/2019
ADHD Testing 09/18/2018 09/18/2019
Adoptive Immunotherapy 04/03/2018 04/03/2019
Affordable Care Act-Preventive Care 09/04/2018 09/04/2019
Alternating Electrical Fields Therapy 10/05/2018 10/05/2019
Apolipoprotein E Genotype or Phenotype 06/19/2018 06/19/2019
Assistant Surgeon Policy 06/05/2018 06/05/2019
Autism Spectrum Disorders 01/30/2018 01/30/2019
Biochemical Markers of Alzheimer’s Disease 05/29/2018 05/29/2019
Biologicals for Wound Care and Procedures 05/01/2018 05/01/2019
Bone Turnover Markers 05/29/2018 05/29/2019
Botilinum Toxin Injection for Chemodenervation 10/02/2018 10/02/2019
Bone Graft Allografts as Standalone Spinal Stabilization Devices 07/17/2018 07/17/2019
Breast Reconstruction Surgery and Prophylactic Mastectomy 09/11/2018 09/11/2019
Breast Reduction Surgery 01/16/2018 01/16/2019
Bronchial Thermoplasty 01/23/2018 01/23/2019
Cancer Chemotherapy Guidelines 11/27/2018 11/27/2019
Cancer Treatment Vaccines 12/24/2018 12/24/2019
Cerliponase alfa (Brineura) for Batten Disease 04/10/2018 04/10/2019
Chiropractic Services 05/22/2108 05/22/2019
Claim Review Process 05/15/2018 05/15/2019
Cochlear Implants and Auditory Brainstem Implants 02/20/2018 02/20/2019
Cold Therapy Devices 05/29/2018 05/29/2019
Computed Tomographic Colonography 01/30/2018 01/30/2019
Coverage Determination Review 08/22/2017 08/22/2018
Custodial Care 02/20/2018 02/20/2019
Deep Brain Stimulation 06/12/2018 06/12/2019
Dental Services 09/04/2018 09/04/2019
Dermatoscopy 02/27/2018 02/27/2019
Diathermy for Pain 02/20/2018 03/28/2019
Digital Breat Tomosynthesis 05/22/2018 05/22/2019
Discography 07/31/2018 07/31/2019
Durable Medical Equipment 05/29/2018 05/29/2019
Epidural Adhesiolysis 08/07/2018 08/07/2019
Eteplirsen (Exondys 51) for Muscular Dystrophy 01/16/2018 01/16/2019
External Counterpulsation/EECP 05/08/2018 05/08/2019
Extracorporeal Shock Wave Treatment 02/20/2018 02/20/2019
Gender Assignment and Reassignment Surgery 04/24/2018 04/24/2019
Genetic Testing 06/26/2018 06/26/2019
Gynecomastia Surgery 02/20/2018 02/20/2019
Heart Transplant Rejection Monitoring (AlloMap) 02/06/2018 02/06/2019
High Frequency Chest Wall Oscillation Vest 01/16/2018 01/16/2019
Hyperbaric Oxygen Therapy 04/03/2018 04/03/2019
Immune Globulin Therapy 01/23/2018 01/23/2019
Incontinence Alarms 06/26/2018 06/26/2019
Infertility/Assisted Reproductive Technology 04/17/2018 04/17/2019
Infliximab Biosimilar Products 03/06/2018 03/06/2019
Intensive Behavioral Therapy for Autism spectrum disorder (ABA) 01/30/2018 01/30/2019
Interspinous Process Decompression System (XStop®) 08/07/2018 08/07/2019
Intraoperative Neurophysiological Monitoring 04/24/2018 04/24/2019
Keratoconus and Medical Contact Lense 01/30/2018 01/30/2019
Preterm Early-Term Deliveries 08/14/2018 08/14/2019
Magnetic Sphincter Augmentation (Linx) for GERD 02/27/2018 02/27/2019
Medical Necessity Definition 01/23/2018 01/23/2019
Medical Necessity Determination 07/03/2018 07/03/2019
Medications Covered Under Medical Insurance Policy 01/23/2018 01/23/2019
Mobile Outpatient Cardiac Monitoring 01/16/2018 01/16/2019
Nerve Graft with Radical Prostatectomy 07/10/2018 07/10/2019
Neuromuscular Re-Education 03/06/2018 03/06/2019
Neuromuscular Stimulation 08/07/2018 08/07/2019
Neutralizing Antibody Testing in Multiple Sclerosis Patients 06/18/2018 06/18/2019
NICU Level of Care 11/27/2018 11/27/2019
Nitric Oxide Inh in Premature 08/14/2018 08/14/2019
Obstructive Sleep Apnea: Diagnosis and Treatment 04/17/2018 04/17/2019
Occipital Nerve Stimulation 04/03/2018 04/03/2019
Occupational Therapy 04/24/2018 04/24/2019
Off-Label Use of FDA Approved Drugs 05/08/2018 05/08/2019
Organ Transplantation 05/22/2018 05/22/2019
Orthoptic and Vision Therapy 01/30/2018 01/30/2019
Outpatient Pulmonary Rehabilitation 07/03/2018 07/03/2019
Panniculectomy - Removal of Redundant Tissue 07/10/2018 07/10/2019
Peer-to-Peer (P2P) Opportunity 01/30/2018 01/30/2019
Peroral Endoscopic Myotomy for Esophageal Achalasia (POEM) 01/23/2018 01/23/2019
Phototherapy (Non-Neonatal) 03/06/2018 03/06/2019
Physical Therapy 01/23/2018 01/23/2019
Private Duty Nursing 03/06/2018 03/06/2019
Prolotherapy 01/16/2018 01/16/2019
Proton Beam Radiation Therapy 03/20/2018 03/20/2019
Psychologic Evaluation for Medical Procedures 02/06/2018 02/06/2019
Psychological Testing 02/06/2018 02/06/2019
Pulsed Dye Laser Treatment 04/03/2018 04/03/2019
Regional Cerebral Blood Flow via Implanted Cerebral Thermal Perfusion Probe 07/03/2018 07/03/2019
Regional Sympathetic Blocks 08/07/2018 08/07/2019
Seizure Disorders: Invasive Treatments (Epilepsy Surgery) 06/05/2018 06/05/2019
Sipuleucel-T (Provenge) 03/13/2018 03/13/2019
Speech Therapy 05/22/2018 05/22/2019
Spinraza (Nusinersen) 06/12/2018 06/12/2019
Synagis (Palivizumab) 10/16/2018 10/16/2019
Talimogene Laherparepvec (Imlygic) 03/13/2018 03/13/2019
Tech Assess of Tests and Assays for Response to Agents 10/22/2015 10/22/2016
Transcatheter Aortic Valve 09/18/2018 09/18/2019
Transcranial Magnetic Stimulation for Depression 09/18/2018 09/18/2019
Transoral Fundoplication 01/23/2018 01/23/2019
Trigger Point Injections 07/17/2018 07/17/2019
Urinary Incontinence Treatments 03/13/2018 03/13/2019
Vagus Nerve Stimulation 08/18/2016 08/18/2017
Ventricular Assist Devices (VAD) 01/16/2018 01/16/2019
Vertebroplasty Kyphoplasty Sacroplasty 08/07/2018 08/07/2019
Vitamin Assays 01/16/2018 01/16/2019
Voretigene Neparvovec-rzyl (Luxturna) 06/26/2018 06/26/2019
Xofigo 02/27/2018 02/27/2019

Text/HTML

Quality Improvement: Clinical Guidelines

Clinical Guidelines

Behavioral Health
Chronic Conditions

Text/HTML

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.

Text/HTML

Medical Management

Medical Authorizations

Medication Authorization

Text/HTML

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.

Text/HTML

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.

Text/HTML

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

Text/HTML

Utilization Management Program

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.

Text/HTML

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.

Text/HTML

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 Care Coordination Division (CCD) at 1-254-298-3088 or 1-888-316-7947 Monday through Friday, 8 a.m. to 5 p.m.

Call a Continuing Care Coordinator 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 (e.g, 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 Care Coordination Division (CCD) 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 CCC 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 justification 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.

CCC, delegated reviewers, or SWHP Claims RN 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 CCC, delegated reviewer, or Claims RN reviews any potential issues regarding medical necessity or appropriateness with the Plan Medical Directors(s). No 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 per the requirements of the Texas Department of Insurance (TDI).

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 Care Coordination Division at 1-254-298-3088 or 1-888-316-7947.

Text/HTML

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.

Jump to Top of This Page