Provider Manual and Training

Jump to Page Topics

• General Provider Resources
• Orientation Training
• SWHP Provider Manual
  • General Information
  • Claims and Billing
  • Fraud, Waste, and Abuse Training for Providers
  • MyBenefits
  • Policies
    • Medical Coverage Policies - documents
    • Reimbursement Policies
    • Other Policies
  • Medical Management
    • Medical Authorizations
    • Medication Authorization
    • Care Coordination - Disease or Case Management
    • Care Guidance - Complex Case Management (CCM)
    • Disease Management
    • Utilization Management Program
    • Technology Assessment
  • Pharmacy Services (links)
  • Provider Rights and Responsibilities
  • Quality Improvement
  • Telemedicine
• Frequently Asked Questions (FAQs) for Medical Providers
• Frequently Asked Questions (FAQs) for Pharmacists

General Provider Resources

Orientation Training

Helpful orientation and education resources for our providers

New to SWHP? Review our orientation videos to learn about our operations, policies, and procedures, and helpful contact information. We also encourage established providers to review our orientations for refreshers and updates. We also provide a guide for our interactive voice response system

Commercial HMO/PPO Plans — Provider Orientation

Medicare Advantage Plan — Provider Orientation

SWHP Provider Interactive Voice Response (IVR) System Guide

SWHP Provider Portal — Provider Training

Provider Webinar Training 2019

SWHP Brown Bag Webinar 11/3/2017

Provider Manual

Welcome to your guide for important provider information.

Download and view our Provider Manual.

Or, quickly find what you're looking for from the topics below.

General Information

• About Us
• Member Confidentiality
• Providers Rights & Responsibilities
• Members Rights & Responsibilities
• Advance Directives
• Advertising of SWHP Name Guidelines
• General Complaint and Appeal Procedures
• SeniorCare Appeals and Grievances Procedures
• Provider Relations Representative Territory Map

Claims and Billing

• Claims and Billing
• Claims and Billing Forms
• How to File a Redetermination
• How to Submit Claims and Guidelines
• How to File an Electronic Claim
• How to File a Paper Claim
• How to Submit a Medicare Claim
• Coordination of Benefits
• Workers’ Compensation (Third-Party Liability)
• Account Reconciliation
• Locum Tenens Billing
• Statutory Verification

Fraud, Waste & Abuse Training for Providers and Pharmacists

The Centers for Medicare and Medicaid Services (CMS) requires all health plans offering Medicare Advantage – Prescription Drug plans ensure participating providers and pharmacists complete Fraud, Waste & Abuse Training annually.* This training must be completed by December 31^st of each year.

If you're a First Tier, Downstream, or Related Entity (FDR) currently enrolled in the Medicare program or accredited as a Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS), we'll consider you as having met the training and educational requirements for fraud, waste & abuse. For additional information, refer to the CMS regulation document. If you have any questions or need assistance with this process, please contact our Compliance Manager at SWHPComplianceDepartment@bswhealth.org or Customer Advocacy Department at 1-800-321-7947.

Pharmacist Fraud, Waste & Abuse Training

All members of the pharmacy staff must complete the Fraud, Waste & Abuse Training. Click here to begin your training online.

Only one FWA Training Attestation Form is required per pharmacy, and it should be completed by the Head Pharmacist or Store Manager.

Provider Fraud, Waste & Abuse Training

If you're a provider, click here to begin your training online.

If you have already completed your training requirements through another mechanism, complete and submit the FWA Training Attestation Form.

*See 42 CFR 422.503, 422.504, 423.504, 423.505 et seq.; see also Centers for Medicare and Medicaid Services, Prescription Drug Benefit Manual, Chapter 9 - Part D Program to Control Fraud, Waste and Abuse.

MyBenefits

• How to Register a New Provider
• FAQs and Troubleshooting Guide

Policies

• Medical Coverage Policies
• Reimbursement Policies
• Other Policies

Medical Management

Medical Authorizations

• Medical Authorizations

Medication Authorization

• Medication Prior Authorizations
• Medication Drug Lists (Formularies)

Care Coordination

• Care Coordination Philosophy and Goals
• Care Guidance - Complex Case Management (CCM)
• Disease Management

Utilization Management

• Utilization Management Program
• Technology Assessment Program
• Technology Assessment Form

Quality Improvement

National Committee for Quality Assurance (NCQA) Accreditation

NCQA Accreditation is a comprehensive evaluation of health plans clinical measures and consumer experience measures. Standards are developed with the help of health plans, providers, insurance customers, unions, regulatory agencies and consumer groups. NCQA's Health Plan Accreditation is considered the industry's gold standard. NCQA Accreditation measures five areas of performance: Staying Healthy, Getting Better, Living with Illness, Access and Service, and Qualified Providers. To see how SWHP Providers measured up, click the link below, then choose "Health Plan Report Card" and search for "Scott and White" to see our ratings.

• Health Plan Report Card

Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS® is a registered trademark of NCQA. SWHP uses HEDIS® to measure clinical quality performance and evaluate areas of care: preventive services, treatment of acute illness, management of chronic illnesses, and patient experience with services provided (as measured through the CAHPS, a standardized survey used by all plans).

Accessibility to Healthcare Services

• Telephone Access Standards
• Accessibility of Services

Purpose and Scope of the QI Program

The purpose of the quality improvement program is to ensure SWHP is providing the highest quality care that is easy to access and affordable to our members regardless of plan type, age, race/ethnicity or health status. SWHP supports and tries to reach "Triple Aim" goals: improving Member's affordability, quality and experience of care. SWHP Quality programs and improvement projects are designed to improve member outcomes through systematic ongoing measurement, provider/member/health plan care coordination, and continuous evaluation of results.

The scope of the QI Program is to monitor, evaluate and improve:

• • The quality and safety of clinical care
• • The quality of service provided by SWHP
• • The quality of practitioners and providers
• • Affordable and accessible health care and wellness
• • The overall Member experience

SWHP strives for personal differentiation. No matter the product, the Member is our focus. SWHP has many examples of helping our members navigate the maze of healthcare, as well as thoughtful interventions that have improved the health outcomes of our Members. SWHP's close connection to both our Members and our provider community places us in a unique position to act as an effective member advocate. As a regional health plan, we have exceptional opportunities to finance health care in a way that is intrinsically superior by aligning incentives, identifying gaps in health care delivery, and facilitating smooth and seamless coordination of care throughout the health care continuum.

QI Program Goals - Objectives

1. Improve Member Health Outcomes - through staying healthy and management of chronic conditions such as the following: Diabetes, Asthma, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Behavioral/Mental Health, Children's' and Women's' Health

2. Improve Medical Safety - by fostering a supportive environment that helps providers to improve the safety of their practice, monitoring SWHP Pharmacy medication safety, monitoring medication errors, and providing Members with information that improves their knowledge about clinical safety in their own care.

3. Increase Member Satisfaction - by prompt identification and resolution of dissatisfaction with administrative or medical processes. Evaluate processes for improvement. SWHP conducts the CAHPS survey to measure Member Satisfaction annually. This survey is use to identify opportunities for improvement.

4. Meet the Cultural and Linguistic Needs of the Member – by identifying language and other cultural/social needs of SWHP Members. We meet those needs by providing bilingual services, translated materials, cultural diversity education, training for SWHP staff and a network of diverse and multilingual providers. SWHP regularly monitors Member demographic data and Member feedback to adjust the provider network and services to reflect the Member's needs.

5. Provide Affordable Care - through reducing the variations in clinical care, preventing overuse, underuse or misuse of services, redirection of care to the most appropriate place, and through continued improvement of all SWHP processes to optimize care and reduce unnecessary care.

6. Organizational Effectiveness – strive to achieve statistically significant improvements in all quality measurements to meet or exceed regional or national averages set forth by National Committee Quality Assurance, Centers for Medicare and Medicaid (CMS), Texas Department of Insurance (TDI) and Texas Health and Human Services Commission (HHSC) or other accepted quality Standards.

Additional Documents

Physician Office Visit Information Form

Clinical Guidelines

Pharmacy Services

• Formularies / Drug Lists
• Pharmacy Locations
• Drug Requests — Prior Authorizations, Exceptions & Appeals

Provider Rights and Responsibilities

Scott and White Health Plan (SWHP) contracted providers are responsible for providing and managing health care services for SWHP members until services are no longer medically necessary.

Provider Rights

Providers have the right to:

• • Be treated courteously and respectfully by SWHP staff at all times.
• • Request information about SWHP's utilization management, case management, and disease guidance programs, services, and staff qualifications and contractual relationships.
• • Upon request, be provided with copies of evidence-based clinical practice guidelines and clinical decision support tools used by SWHP.
• • Be supported by SWHP to make decisions interactively with members regarding their health care.
• • Consult with SWHP Medical Directors at any point in a member's participation in utilization management, case management, or disease guidance programs.
• • Provide input into the development of SWHP's Case Management and Disease Guidance Programs.
• • File a complaint on own behalf of a SWHP member, without fear of retaliation, and to have those complaints resolved.
• • Receive a written decision regarding an application to participate with SWHP within 90 days of providing the complete application.
• • Communicate openly with patients about all diagnostic testing and treatment options.
• • The right to appeal claims payment issues.
• • The right to 90 days prior written notice of termination of the contract.
• • The right to request a written reason for the termination, if one is not provided with the notice of termination.

Provider Responsibilities

Primary Care Physicians (PCPs):

• • Provide primary health care services not requiring specialized care. (i.e., routine preventive health screening and physical examinations, routine immunizations, routine office visits for illnesses or injuries, and medical management of chronic conditions not requiring a specialist)
• • Obtain all required pre-authorizations as outlined in the Provider Manual.
• • Refer SWHP members to SWHP contracted (in-network) specialists, facilities, and ancillary providers when necessary.
• • Assure SWHP members understand the scope of specialty and/or ancillary services that have been authorized and how or where the member should access the care.
• • Communicate a SWHP member's medical condition, treatment plans, and approved authorizations for services to appropriate specialists and other providers.
• • Keep panel open to SWHP members until it contains at least 100 SWHP members on average per individual PCP.
• • Will give SWHP at least 7 days advance written notice of intent to close panel and may not close panel to SWHP unless closing panel to all payors.

Specialists:

• • Deliver all authorized medical health care services related to the SWHP member's medical condition as it pertains to specialty.
• • Deliver all medical health care services available to SWHP members though self-referral benefits.
• • Determine when the SWHP member may require the services of other specialists or ancillary providers for further diagnosis or specialized treatment, as well as, if the member requires admission to a hospital, rehabilitation facility, skilled nursing facility, or etc.
• • Provide verbal or written consult reports to the SWHP member's PCP for review and inclusion in the member's primary care medical record.

All Providers:

• • Follow SWHP's administrative policies and procedures and clinical guidelines when providing or managing health care services within the scope of a SWHP member's benefit plan.
• • Uphold all applicable responsibilities outlined in the SWHP Member Rights & Responsibilities Statement.
• • Maintain open communications with SWHP members to discuss treatment needs and recommended alternatives, regardless of benefit limitations or SWHP administrative policies and procedures.
• • Provide timely transfer of SWHP member medical records if a member selects a new primary care practitioner, or if the practitioner's participation with SWHP terminates.
• • Participate in SWHP Quality Improvement Programs, which are designed to identify opportunities for improving health care provided to SWHP members and the related outcomes.
• • Comply with all utilization management decisions rendered by SWHP.
• • Respond to SWHP Provider Satisfaction Surveys.
• • Provide SWHP with any SWHP member's written complaints or grievances against provider or practice immediately (within 24 hours). The process for resolving complaints should be posted in the provider's office or facility and should include the Texas Department of Insurance's toll free number.

Providers should notify SWHP when there are changes to their practice, such as:

• • Change of ownership and tax identification number (TIN).
• • Change of address (service/mailing/billing), phone number, or fax number.
• • New provider added to group or practice.
• • Provider terminations from group or practice.
• • Adverse actions impacting practitioner's ability to provide services.
• • Termination from or opt out of participation in Medicare or Medicaid.

All changes reported should include an effective date.

This page updated August 4,2014

Telemedicine

• About Telemedicine
• Provider Login
• Create an Account
• You may also request it from your Provider Representative or by calling SWHP.