Inpatient Services
Hospitalization
Admission or Observation Status
Scott & White Health Plan (SWHP) members are covered for life-threatening urgent/emergent care at any time in any facility. If a SWHP member requires observation and/or admission to a hospital, SWHP must be notified within 24-48 hours of admission in order to receive consideration of SWHP coverage for the stay. Health Services Division (HSD) of SWHP should be contacted at 254-298-3088 or 1-888-316-7947 Monday-Friday, 8 a.m. to 5 p.m. After-hours, weekends, holidays, please call Scott & White's main facility in Temple at 254-724-2111. You may request that a SWHP nurse Continuing Care Coordinator is contacted to speak with you. The following information is needed:
- Member Name and/or Membership Number from SWHP card
- Day and Time of Admission or Observation
- Route of Admission (i.e., ER, Urgent, Scheduled Clinic Admit, etc.)
- Facility Name and Telephone Number(s)
- Admitting/Attending Physician or Provider
- Telephone Number for Physician(s), Provider(s), and/or the Utilization Review (U.R.) Dept.
- Admitting Diagnosis
- Procedure(s) Performed/Scheduled
HSD staff will provide a confirmation number to facility. This is used on billing and indicates that admission (observation) has been called in within the authorized time frame. This is not an authorization for payment. A SWHP Nurse Continuing Care Coordinator (CCC) provides member benefits and approved length-of-stay (LOS). The CCC may need to obtain a report from the Physician and/or Utilization Review/Case Management Department of the facility prior to determining SWHP coverage.
Pre-Admission Certification:
All elective/scheduled admissions for selected procedures must be prior approved by SWHP Medical Director(s) through use of the Authorization Forms.
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). 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 SWHP HSD does not authorize an extension of hospital days based on submitted medical justification, those days will not be paid.