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Providers » Provider Orientation/Education

Orientation/Education Check List

Online Provider Orientation/Education Checklist

  1. SWHP Web site - www.swhp.org
  2. Provider Manual - Go to www.swhp.org, under Provider, select Provider Manual.
  3. MyBenefits Provider Module -Go to www.swhp.org, click on MyBenefits Provider Module to receive the quickest response when confirming member eligibility/benefits and claims status information.
  4. Member Identification Card - Go to www.swhp.org, under Provider, select Provider Manual, click on Member Identification Card section.
    • PCP - The Primary Care Provider is not printed on the member ID card. Instead members will receive a letter confirming their PCP selection.
    • Copayments and Deductibles - Office Visit, Emergency/Urgent Visit, and Prescription copayments are listed on the member ID card. Medical deductibles are not listed.
    • Plan Type - This field on the ID card indicates the type of medical coverage (HMO, Consumer Choice, Major Medical, Point of Service, High Deductible Health Plan, etc.).
    • Member Names and Numbers - The member ID card will list the subscriber and up to seven dependents on one card. This eliminates the need for families to carry cards for each dependent of the family.

    5. To prevent a claim rejection, a claim must be filed with appropriate member name and complete eleven digit member ID number. A claim will reject when filing with the nine digit contract number only. It is important to include the member number with the two digit suffix because it identifies the specific individual member. See member ID card example below.

    Member ID Card sample

    Please access the MyBenefits Provider module at www.swhp.org to confirm member eligibility and benefits. If you do not have internet access, please call the Customer Service Center at 1-800-321-7947 for assistance

    Scott & White Health Plan does not pay for services rendered to patients who are not eligible for coverage. If you are denied payment for services provided to a non-eligible patient, you may then bill the patient full charges.

  5. Primary Care Program - In-network referrals do not require preauthorization and no forms are necessary for SWHP. PCPs may need to complete a provider required referral form at their request but is not required by SWHP for payment purposes. Please note, certain services do require an authorization and those can be found under the Preauthorization/Authorization of Service section. Authorizations are only needed for out of network referrals.
  6. Laboratory Services - A list of pathology CPT codes approved for a physician's office were provided with your contract. All other pathology services should be referred to a contracted lab provider. Go to www.swhp.org, under Provider, select Provider Directory, click on Specialty Care Physicians and Other Providers. The contracted lab providers are listed under Clinical Pathology/Lab specialty by city.
  7. Radiology Services - A list of radiology CPT codes approved for a physician's office were provided with your contract. All other radiology services should be referred to a contracted radiology provider. Go to www.swhp.org, under Provider, select Provider Directory, click on Specialty Care Physicians and Other Providers. The contracted radiology providers are listed under Imaging Center specialty by city.
  8. Preauthorization/Authorization of Services- Go to www.swhp.org, under Provider, select Provider Manual, click on Preauthorization/Authorization of Services section.
    • Some outpatient procedures, invasive diagnostic procedures, and other outpatient services as well as all out of network referrals require preauthorization through SWHP Health Services Division. This is facilitated by completing SWHP Authorization Forms and faxing to the SWHP Health Services Division at 1-800-626-3042 (toll free fax server number) and/or 254-298-3450 (local fax server number).
    • For questions, contact SWHP Health Services Division at 1-888-316-7947 (toll free number) or 254-298-3088 (local number).
  9. Filing claims - Go to www.swhp.org, under Provider, select Provider Manual, click on Claims and Billing section.
    • Electronic claims - Availity - www.avality.com or 1-800-AVAILITY (282-4548)
    • Claims Submission
    • Clean Claim Information
    • Claim Check Edits
    • Claim Appeal/Reconsideration Review Process
    • SeniorCare Claims - SeniorCare is an enhancement program to Medicare Coverage. SWHP has a contractual arrangement with CMS to administer this program. SWHP acts as the Medicare Intermediary for Part B services for SeniorCare members only.

      Part A Services - All claims billed on a UB04 for Part A services should be filed with Medicare Part A and filed secondary with SWHP for possible secondary coverage.

      Part B Services - Check your provider contract for specifics on Part B billing.

  10. Physician's Office DME/Supplies Policy - Go to www.swhp.org, under Provider, select Provider Manual, click on Physician's Office DME/Supplies Policy section.
  11. Pharmacy Services - Go to www.swhp.org, under Provider, select Provider Manual, click on Pharmacy Services section.
  12. Specialty Drugs - Go to www.swhp.org, under Provider, select Provider Manual, click on Pharmacy Services section.
    • Medmark Specialty Pharmacy is the preferred provider for self-injectable, infusion, and advance oral drugs. Prior authorization is required when ordering these specialty drugs.
    • Specialty Formulary
    • Specialty Drug Request Form
    • For questions, contact Medmark directly at 1-888-347-3416
  13. Member's Rights and Responsibilities- Policy and Procedure - Go to www.swhp.org, under Provider, select Provider Manual, click on General Information section.
  14. Change Provider Information - Go to www.swhp.org, select Provider Data Update Notification, then click on Provider Data Update Form. Please fill out appropriate information and send form to SWHP Provider Relations department Email address: swhpproviderrelationsdepartment@swmail.sw.org.
  15. Our Plans and Products - Our portfolio of SWHP products offer a variety of plans for both small and large employer groups as well as individuals. These products include: Traditional HMO, Consumer Choice HMO, Individual Plans, POS (Point of Service Rider), and Consumer-driven Plans compatible with Health Savings Accounts (HSA) and Health Reimbursement Accounts (HRA). SWHP members may be responsible for co-pays, deductibles and coinsurance based on their plan benefits. For more details, go to www.swhp.org, click on the Individual and Family Plans, Employer Plans, and Medicare Plans links.
  16. SWHP VitalCare Management Programs provide our members with the tools and resources they need to better manage their daily and long term health status by helping them follow their physician's treatment plans. To find out more, go to the www.swhp.org, click on the VitalCare link.