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IMPORTANT NOTICES

Peer to Peer Requirements

Prior to issuing a medical necessity denial in response to an authorization request for medical or pharmacy services, a representative calls the treating provider and offers to schedule a peer-to-peer review. The review should take place prior to issuance of the denial. Scott and White Health Plan (SWHP) requests providers to promptly respond to the peer to peer request in order to ensure a timely and effective review of authorization requests for medical services.

To increase communication with SWHP providers across all lines of business, we would like to take this opportunity to outline the regulatory requirements for peer-to-peer or P2P.

Self-Insured (regulated by ERISA): ERISA guidelines do not require P2P for self-insured policy holders, however the provider will be contacted to allow submission of additional information prior to rendering a decision.

Medicare, Commercial (regulated by TDI), FEHB (regulated by OPM), Medicaid: Before a denial is issued, the provider of record is afforded a reasonable opportunity to discuss the services under review during normal business hours. Providers are required to respond in a timely manner to accept the opportunity.

Contact Customer Service at (254) 298-3000 if you have any additional questions.

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.

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New Prior Authorization Requirements — Evicore

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Log In to Your Provider Account

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

Create an Account

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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

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.

Each list includes statistics on:

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

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Medical Coverage Policies

(in alphabetical order)

Last Revised

Next Review Date

001 Acupuncture 02/27/2020 02/27/2021
218 ADHD Testing 11/21/2019 11/21/2020
241 Adoptive Immunotherapy 10/17/2019 10/17/2020
226 Alternating Electrical Fields Therapy 01/23/2020 01/23/2021
014 Apolipoprotein E Genotype or Phenotype 09/26/2019 09/26/2020
248 Assistant Surgeon Policy 08/22/2019 08/22/2020
206 Autism Coverage Policy 05/22/2019 05/22/2020
029 Biochemical Markers of Alzheimer’s Disease 08/22/2019 08/22/2020
210 Biologicals for Wound Care and Procedures 10/31/2019 10/31/2020
030 Bone Turnover Markers 08/22/2019 08/22/2020
011 Botilinum Toxin Injection for Chemodenervation 11/21/2019 11/21/2020
051 Bone Graft Allografts as Standalone Spinal Stabilization Devices 09/26/2019 09/26/2020
209 Breast Reduction Surgery 05/28/2020 05/28/2021
207 Bronchial Thermoplasty 01/23/2020 01/23/2021
255 Cablivi (Caplacizumab) 07/25/2019 07/25/2020
219 Cancer Chemotherapy Guidelines 04/22/2020 04/22/2021
050 Cancer Treatment Vaccines 01/23/2020 01/23/2021
065 Cardiac Monitoring - Outpatient 01/23/2020 01/23/2021
238 Cerliponase alfa (Brineura) for Batten Disease 02/27/2020 02/27/2021
214 Chiropractic Services 08/22/2019 08/22/2020
247 Claim Review Process 10/17/2019 10/17/2020
035 Cold Therapy Devices 08/22/2019 08/22/2020
263 Cosmetic Procedures and Treatment 05/28/2020 05/28/2021
213 Coverage Determination Review 03/28/2019 03/28/2020
262 COVID-19 Telehealth and Telemedicine 05/21/2020 As necessary
042 Custodial Care 05/22/2019 05/22/2020
025 Deep Brain Stimulation 05/28/2020 05/28/2021
026 Dental Services and Anesthesia 04/22/2020 04/22/2021
049 Dermatoscopy 06/27/2019 06/27/2020
027 Diathermy for Pain 04/22/2020 04/22/2021
072 Discography 09/26/2019 09/26/2020
028 Durable Medical Equipment 08/22/2019 08/22/2020
031 Epidural Adhesiolysis 10/17/2019 10/17/2020
237 Eteplirsen (Exondys 51) for Muscular Dystrophy 01/23/2020 01/23/2021
221 External Counterpulsation/EECP 07/25/2019 07/25/2020
258 Fetal Surgery 05/28/2020 05/28/2021
254 Gamifant (Emapalumab) 07/25/2019 07/25/2020
064 Gender Assignment and Reassignment Surgery 05/28/2020 05/28/2021
037 Genetic Testing 05/28/2020 05/28/2021
259 Golodirsen (Vyondys 53) for treatment of Duchenne muscular dystrophy (DMD) 01/23/2020 01/23/2021
041 High Frequency Chest Wall Oscillation Vest 01/08/2019 01/08/2020
044 Hyperbaric Oxygen Therapy 06/27/2019 06/27/2020
045 Immune Globulin Therapy 05/22/2019 05/22/2020
048 Incontinence Alarms 09/26/2019 09/26/2020
052 Incontinence Treatments 05/28/2020 05/28/2021
141 Infertility/Assisted Reproductive Technology 07/25/2019 07/25/2020
239 Infliximab Biosimilar Products 02/27/2020 02/27/2021
056 Interspinous Process Decompression System (XStop®) 10/31/2019 10/31/2020
234 Intraoperative Neurophysiological Monitoring 07/25/2019 07/25/2020
229 Keratoconus and Medical Contact Lens 04/22/2020 04/22/2021
099 Laser Treatment of Skin Lesions 05/28/2020 05/28/2021
233 Magnetic Sphincter Augmentation (Linx) for GERD 07/25/2019 07/25/2020
243 Medical Necessity Definition 02/27/2020 02/27/2021
213 Medical Necessity Determination 02/27/2020 02/27/2021
215 Medications Covered Under Medical Insurance Policy 05/22/2019 05/22/2020
236 Medications, Services & Supplies NOT Medically Necessary 04/22/2020 (OPEN)
060 Nerve Graft with Radical Prostatectomy 09/26/2019 09/26/2020
251 Neuromuscular Stimulation 11/21/2019 11/21/2020
067 Neutralizing Antibody Testing in Multiple Sclerosis Patients 09/26/2019 09/26/2020
250 NICU Level of Care 02/27/2020 02/27/2021
217 Nitric Oxide Inh in Premature 10/31/2019 10/31/2020
110 Obstructive Sleep Apnea: Diagnosis and Treatment 04/22/2020 04/22/2022
074 Occipital Nerve Stimulation 06/27/2019 06/27/2020
003 Occupational Therapy 07/25/2019 07/25/2020
062 Off-Label Use of FDA Approved Drugs 05/22/2019 05/22/2020
129 Organ Transplantation 05/28/2020 05/28/2021
211 Orthoptic and Vision Therapy 02/27/2020 02/27/2021
070 Outpatient Pulmonary Rehabilitation 09/26/2019 09/26/2020
083 Panniculectomy - Removal of Redundant Tissue 09/17/2019 09/17/2020
244 Peer-to-Peer (P2P) Opportunity 05/22/2019 05/22/2020
228 Peroral Endoscopic Myotomy for Esophageal Achalasia (POEM) 01/23/2020 01/23/2021
128 Phototherapy (Non-Neonatal) 06/27/2019 06/27/2020
004 Physical Therapy 02/27/2020 02/27/2021
216 Preterm Early-Term Deliveries 10/17/2019 10/17/2020
063 Preventive Care - Affordable Care Act 08/22/2019 08/22/2020
208 Private Duty Nursing 06/27/2019 06/27/2020
075 Prolotherapy 1/23/2020 1/23/2021
137 Psychologic Evaluation for Medical Procedures 06/27/2019 06/27/2020
224 Psychological Testing 05/28/2020 05/28/2021
058 Regional Cerebral Blood Flow via Implanted Cerebral Thermal Perfusion Probe 09/26/2019 09/26/2020
101 Regional Sympathetic Blocks 10/31/2019 10/31/2020
013 Seizure Disorders: Invasive Treatments (Epilepsy Surgery) 08/22/2019 08/22/2020
032 Shockwave Treatment - Plantar Fasciitis 04/22/2020 04/22/2021
246 Sipuleucel-T (Provenge) 04/25/2019 04/25/2020
112 Speech Therapy 08/22/2019 08/22/2020
230 Spinraza (Nusinersen) 02/27/2020 02/27/2021
257 Spravato (Esketamine) 07/25/2019 07/25/2020
235 Synagis (Palivizumab) 08/22/2019 08/22/2020
204 Transcatheter Aortic Valve Replacement 05/28/2020 05/28/2021
227 Transoral Fundoplication 01/23/2020 01/23/2021
081 Trigger Point Injections 10/17/2019 10/17/2020
252 Urine Drug Monitoring 05/22/2019 05/22/2020
201 Ventricular Assist Devices (VAD) 05/28/2020 05/28/2021
084 Vertebroplasty Kyphoplasty Sacroplasty 10/31/2019 10/31/2020
242 Vitamin Assays 09/26/2019 09/26/2020
249 Voretigene Neparvovec-rzyl (Luxturna) 04/22/2020 04/22/2020
253 Zolgensma (Onasemnogene Abeparvovec) 08/29/2019 08/29/2020
256 Zulresso (Brexanolone) 07/25/2019 07/25/2020

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Quality Improvement: Clinical Guidelines

Clinical Guidelines

Behavioral Health
Chronic Conditions

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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.

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Medical Management

Medical Authorizations

Medication Authorization

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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.

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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.

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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

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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.

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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.

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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 or 1-888-316-7947.

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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.

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