Scott & White Health Plan

Benefits and Eligibility  •  Claims and Billing  •  Medical Management  •  Quality Improvement  •  Complaints and Appeals  •  Pharmacy Services-Prior Auth/Formularies  •   Provider Directory  •  General Information

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Benefits and Eligibility

• MyBenefits Provider Module 
  • MyBenefits User Guide 
  • MyBenefits Quick Reference Guide 
  • MyBenefits Sign On Request Form
     
• Member Eligibility Verification Procedures
  • Quick Guide
     
• Member Identification Card
   
• SeniorCare Program
  • Summary of Benefits
  • 2012 SeniorCare Plan Comparison Chart
  • 2012 Medicare Part D Rx Plan Comparison Chart
  • SeniorCare Formulary
     
• Frequently Asked Questions

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Claims and Billing

• Introduction
   
• Commitment to Quality
    Claims Guidelines and Submission
  • Filing deadline
  • Clean claim
• Paper Claims
  • Completing a paper CMS 1500 Form
  • Completing a paper UB 04 For 
• Electronic claims
  • Submitting claims directly to SWHP electronically
  • Submitting claims thru a clearing house
  • Electronic Data Interchange (EDI) Intake Form
  • Electronic Data Interchange (EDI) Authorization Form
     
• Appeals
  • Provider Appeals
  • Filing Limit Provider Appeals
  • Duplicate and Corrected Provider Claim Appeals
  • Provider Appeal Request Form
     
• Provider Reimbursement
  • Claim Check
  • Modifier Payment Policy
  • Modifier Priority Table
  • Bilateral and Multiple Surgical Procedures Professional Payment Policy
  • Balance Billing
     
• Claim Status Inquiry
  • MyBenefits Provider Module (Provider link/Sign On Request Form)
  • Customer Service Advocates
  • Balance Billing
     
• Coordination of Benefits
  • Coordination Of Benefits Policy
  • Medicare Coordination Of Benefits Guidelines
     
• SeniorCare Policyholders Claims
   
• Third Party Liability
  • Workers Compensation
  • Subrogation
  • Ingenix Accident Report
     
• Account Reconciliation
  • Negative Balance
  • Retractions/recoupments, Returned Checks, and Refund Checks
     
• Statutory Verification/Declination
   
• Locum Tenens Billing
   
• Frequently Asked Questions

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Medical Management

• Primary Care Physician Program

  • Request for Designation as Secondary Care Physician for a Health Plan
  • Term Physician/Patient letter
  • Specialist as Primary Care Physician
  • Request for Non-PCP Specialist to function as PCP
     
• Physician's Office DME/Supplies Policy
   

• Physician Referral Processes

  • Physician Referral Network
  • Out-of-Network Referrals
     

• Forms

  • General/Medical/Surgical
  • Mental/Behavioral Health
  • SWHP S&W System Providers Technical Assessment Form (pdf)
  • SWHP S&W System Providers Technical Assessment Form (excel)
  • SWHP Non-S&W System Providers Technical Assessment Form (pdf)
  • SWHP Non-S&W System Providers Technical Assessment Form (excel)
  • Case Management forms
    • Provider Referral Form
    • Facility / Hospital Referral Form
    • Customer Service Referral Form
       

• VitalCare Utilization Management Programs

• Health Services Division Philosophy and Goals
• Hospitalization Procedures
• SWHP Utilization Management - Inpatient Services
• Outpatient Services Preauthorization
• Forms
  • General/Medical/Surgical
  • Mental/Behavioral Health
• Utilization Management Program Description
• Health Care Management Guidelines
• Interqual Criteria
• Utilization of Services
• Technology Assessment Program
  • SWHP S&W System Providers Technical Assessment Form (pdf)
  • SWHP S&W System Providers Technical Assessment Form (excel)
  • SWHP Non-S&W System Providers Technical Assessment Form (pdf)
  • SWHP Non-S&W System Providers Technical Assessment Form (excel)
• Complex Case Management
• Disease Management/Condition Management
• Cooperative Care (Medical Home)
• Other VitalCare Resources
     
• Medical Policies
   
• Frequently Asked Questions
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Quality Improvement

• Healthcare Effectiveness Data and Information Set (HEDIS®) - Service levels
• HEDIS® Guide 2011
  HEDIS® is a registered trademark of NCQA.
   
• Quality Improvement Program
  • Clinical Guidelines
     
• Accessibility to Healthcare Services
  • Standards for Timely Primary Care Access
  • Standards for Timely Behavioral Health Access and Behavioral Health Telephone Access
     
• Physician Office Visit Information Form
   
• Frequently Asked Questions

Complaints and Appeals

• Member Complaint & Appeal Procedure
   
• SeniorCare Complaint & Appeal Procedure
   
• Physician Appeals Policy
  • Practitioner/Appeal Request Form
     
• Frequently Asked Questions

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Pharmacy Services-Prior Auth/Formularies

• Prescription Drug Benefit Summary
   
• Overview of Scott & White Health Plan Formulary
   

• Formularies

  • Scott & White Health Plan
    • Alphabetical
    • Therapeutic Category
    • Specialty Formulary
    • Formulary Changes
  • Hillcrest Preferred Drug List - Please be advised that the formulary for the Hillcrest Employee Medical Plan may have changed for 2011. It is not the same as the standard SWHP formulary.
  • Metroplex Preferred Drug List
  • Medicare Part D Formulary
    • SeniorCare Formulary
       
         
• Formulary Addition Request Form/Instructions
   

• Prior Authorization Forms/Formulary Exception Request Form

  • Scott & White HMO
    • Byetta® (exenatide)
    • Orencia® (abatacept)
    • Pradaxa (dabigatran)
    • Synagis 2011-2012
    • Other drugs
  • Medicare Part D
    • Medicare Part D Coverage Determination Request
    • Medicare Part D Redetermination Request
  • Medicare Part B
    • Hyaluronic acids (e.g. Synvisc®, Supartz®, etc.)
    • Reclast® (zoledronic acid 
• Specialty Drug Request Form
   
• Medical Coverage Policy (Medications)
   
• Scott & White Health Plan Pharmacies
   
• Scott & White Health Plan Network Pharmacies
   
• Frequently Asked Questions

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Provider Directory

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General Information

• About Us
   
• Mission Statement
  • Preface
  • Texas Friendly
     
• Confidentiality Statement
   
• Members Rights and Responsibilities-Policy and Procedures
  • SWHP Members Rights and Responsibilities
  • Refusal of Treatment Policy
  • Complaint and Appeals Procedure
  • SeniorCare Complaint and Appeals Procedure
     
• Physician Advertising-Policy and Procedures
   
• Provider Resources
  • Online Training Programs
  • MyBenefits Provider Module
  • Find a Form
  • Provider Newsletters
  • Provider Data Update Notification
  • Our Plans and Products
    • Individual and Family Plans
    • Employer Group Plans 
    • Medicare Plans
       
• Contact Us
   
• Frequently Asked Questions

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