provider reference guide...2020 provider reference guide group products no referrals are required in...

2 02 0 P rov i d e r Re fe re n ce G u i d e

PROVIDER REFERENCE GUIDE


HELPFUL PLAN INFORMATION Commercial & Medicare Medicaid

Provider Portal portal.swhp.org/ProviderPortal/#/login rightcare.firstcare.com

Website Resources

Provider Home Pageswhp.org/prov

Provider Manualswhp.org/prov/resources/provider-manual

Forms and Toolsswhp.org/prov/forms-guides

Provider Search Toolportal.swhp.org/#/search

Provider Home Pagerightcare.swhp.org/prov/provider-home

Provider Manualrightcare.swhp.org/prov/provider-manual

Forms and Toolsrightcare.swhp.org/prov/forms-tools

Provider Search Toolportal.swhp.org/#/search

Claims/Eligibility Verification

Provider Portalportal.swhp.org/ProviderPortal/#/loginEligibility Verification Line (IVR Line): 800-655-7947 or 800-321-7947

Provider Portal rightcare.firstcare.comTexMedConnect www.tmhp.com Customer Service855-TX-RIGHT (855-897-4448)

Claims Filing

Electronic Clearinghouse AvailityPayor ID: 88030

Initial Filing Deadline 95/365 (Commercial/Medicare) days from date of service

Corrected Filing Deadline 90/365 (Commercial/Medicare) days from the date of determination on the initially filed clean claim

Paper Claims Filing AddressScott and White Health PlanATTN: Claims Review Dept.PO Box 21800Eagan, MN 55121-0800

More Informationswhp.org/prov/claims/how-to-submit

swhp.org/prov/claims/electronic

swhp.org/prov/claims/paper

Electronic Clearinghouse Change HealthcarePayor ID: 74205Initial Filing Deadline95 days from date of serviceCorrected Filing Deadline 120 days from the date of disposition

Paper Claims with DOS prior to 11/1/2019RightCare from Scott and White Health Plan c/o Valence Health 300 S. Riverside Plaza, Suite 700 Chicago, IL 60606

Paper Claims with DOS on/after 11/1/2019 Scott and White Health Plan ATTN: RightCare PO BOX 971727 El Paso, TX 79998-1727

More Information Change Healthcare Customer Service 877-667-1512

Appeals/Redeterminations

Filing Deadline From the original determination date: 90 days (Commercial and Medicare Cost) 120 days (Medicare Advantage) 1 year (out-of-state providers)Appeals AddressScott and White Health Plan ATTN: Provider Claims Redetermination PO Box 21800 Eagan, MN 55121-0800Redetermination Submission Paper: swhp.org/prov/claims/resources/appealsElectronic: portal.swhp.org/ProviderPortal/#/login (Preferred Method)

Paper Claims Filing Address Claims with a DOS prior to 11/1/2019 should be sent to:Scott and White Health PlanATTN: RightCareMS-A4-144, Medicaid Appeals1206 West Campus DriveTemple, TX 76502-9915Claims with a DOS on/after 11/1/2019 should be sent to:Scott and White Health PlanATTN: RightCarePO BOX 971727El Paso, TX 79998-1727 Electronic submission through provider portal: rightcare.firstcare.com/Web/

https://portal.swhp.org/ProviderPortal/#/login

https://rightcare.firstcare.com

http://swhp.org/en-us/prov

http://swhp.org/en-us/prov/resources/provider-manual

http://swhp.org/en-us/prov/ forms-guides

https://portal.swhp.org/#/search

http://rightcare.swhp.org/prov/provider-home

http://rightcare.swhp.org/en-us/prov/provider-manual

http://rightcare.swhp.org/en-us/prov/forms-tools

https://portal.swhp.org/#/search



http://www.tmhp.com

http://swhp.org/en-us/prov/claims/how-to-submit

http://swhp.org/en-us/prov/claims/electronic

http://swhp.org/en-us/prov/claims/electronic

http://swhp.org/en-us/prov/claims/paper

http://swhp.org/en-us/prov/claims/resources/appeals

http://swhp.org/en-us/prov/claims/resources/appeals



https://rightcare.firstcare.com/Web/


Commercial & Medicare Medicaid

Payment Methods

Providers will be reimbursed through a Virtual Credit Card (VCC) unless they opt out.

To opt out of VCC, contact:

Change Healthcare(855) 886-3863 — select option 1

To select Automatic Clearinghouse (ACH) or Electronic Funds Transfer (EFT), contact:

Change Healthcare (866) 506-2830 — select option 1

Providers receive a paper check unless they enroll in EFT by registering with Change Healthcare.

To register with Change Healthcare: changehealthcare.com/EFT

Refund Requests

Mail Refund RequestsScott and White Health PlanATTN: Claim RefundsPO Box 840523Dallas, TX 75284-0523

More informationswhp.org/prov/claims/paper

Mail Refund RequestsScott and White Health PlanATTN: RightCarePO Box 841476Dallas, Texas 75284-1476

More information rightcare.swhp.org/prov/forms-tools

Prior Authorization

PA List and Request Form swhp.org/prov/auth-referral/medical

SWHP Health Services Division888-316-7947 or 254-298-3088

PA look-up tool portal.swhp.org/ProviderPortal/#/login (Link contains information regarding eviCore and Oncology Analytics)

PA List and Request Form rightcare.swhp.org

PA Portal Request rightcare.firstcare.com

Medical Management Phone: 855-691-7947 Fax: 800-292-1349

Behavioral Health Management Phone: 855-395-9652 Fax: 844-436-8779

Pharmacy Resources

Pharmacy Services swhp.org/prov/resources/pharmacy-services

Medication Authorization Forms swhp.org/prov/auth-referral/medications

Prescription Drug Lists swhp.org/prov/resources/pharmacy-services/drug-list

Pharmacy Notifications and Prior Authorizationsrightcare.swhp.org/prov/authorizations

Prescribing Providers 877-908-6023

Pharmacy Providers877-908-6023

SWHP Contact Information

Provider Relations Phone: 800-321-7947 or 254-298-3064 Fax: 254-298-3044

Customer Advocacy Commercial: 800-321-7947 Medicaid: 855-897-4448 Medicare: 866-334-3141 (TTY 711)

HELPFUL PLAN INFORMATION

http://www.changehealthcare.com/eft

http://swhp.org/en-us/prov/claims/paper

http://rightcare.swhp.org/en-us/prov/forms-tools

http://swhp.org/en-us/prov/auth-referral/medical


http://rightcare.swhp.org/en-us/


http://swhp.org/en-us/prov/resources/pharmacy-services

http://swhp.org/en-us/prov/resources/pharmacy-services

http://swhp.org/en-us/prov/auth-referral/medications

http://swhp.org/en-us/prov/resources/pharmacy-services/drug-list

http://swhp.org/en-us/prov/resources/pharmacy-services/drug-list

http://rightcare.swhp.org/en-us/prov/authorizations


ID Card Overview

Claims mailing address and electronic claims submission ID

Plan type: HMO, HMO-POS, PPO, EPO

5

6

Group number, pharmacy plan

number and pharmacy copay

information

Benefits administrator/insurance carrier

2

Member number

Coverage information

Information for providers

7

3

5

1

6

88

7

2

3........

1

RX BIN:Network:Primary:Specialist:

..........JOHN DOE

Contract No.:

RX PCN:

Issue Date:

Member No. Member Name123456789001234567890112345678902

JOHN DOEJAMIE DOEJACKSON DOE

TDI

RX Group: Urgent:

HMO

SWHP Group No.:

Emergency:RX Copay:

123456789

Please contact Scott & White Health Plan Health Services Departmenttoll free at 866-384-3488 for pre-authorization requests (including BehavioralHealth and Second Opinions). If you require inpatient admission following anemergency, please notify SWHP within 48 hours of emergency services.

Plan Information/provider list: swhp.org ..Nurse Advice Line: 877-505-7947Customer Service: 800-321-7947 ............OptumRx Help Desk: 855-205-9182

Notice To ProvidersVerify benefits and eligibility at portal.swhp.org/providerportal or 800-321-7947

Please send claims and related correspondence to:Scott & White Health Plan | Availity Payer ID 88030Attn: Claims PO Box 21800, Eagan, MN 55121-0800254-298-3000 or 800-321-7947

NOTICE: Possession of this card or obtaining precertification does notguarantee coverage or payment for the service or procedure reviewed.

4

4Helpful

information for members


GROUP PRODUCTS

No referrals are required in any of our networks. HMO and EPO plans offer in-network benefits only, except in cases of emergency or urgent care. HMO-POS and PPO plans offer both in- and out-of-network benefits (members pay a higher cost share for out-of-network services).

RX PCN:Office Visit:Specialist:ER/Urgent:

123456789JOHN DOE

RX BIN:

RX Group:

Issue Date:Group No.:



RX Copay:

HMO

TDI

/

Contract No.:

93078RX BIN:

Office Visit:Specialist:ER/Urgent::

12345678900JOHN DOE

Group No.:

RX PCN:

In/Out of NetworkIssue Date:



RX Copay:

HMO-POS

TDI

/

Member No.://


Plan Information/provider list: swhp.org Nurse Advice Line: 877-505-7947Customer Service: 800-321-7947 Pharmacy Help Desk: 800-728-7947




RX BIN:Issue Date:Primary:Specialist:

123456789JOHN DOE

Group No.:

RX PCN:

PPO



RX Group: Urgent:

Contract No.:

Emergency:RX Copay:

RX BIN:Primary:Specialist:Urgent:

123456789JOHN DOE

Group No.:

RX PCN:

Issue Date:



TDI

RX Group: Emergency:

EPO

Contract No.:

RX Copay:

TDI

Universal card back for group HMO, HMO-POS, PPO and EPO.

Our commercial group products include HMO, HMO-POS, PPO, EPO, and Out-of-Area options for small, large, and self-funded employers.

Standard ID card samples:group-specific variations may occur.

RX BIN:Primary:Specialist:Urgent:

123456789JOHN DOE

Group No.:

RX PCN:

Issue Date:



TDI

RX Group: Emergency:

Contract No.:

RX Copay:


Plan Information/provider list:

swhp.org

..Nurse Advice Line: 877-505-7947Customer Service: 800-321-7947 ............Pharmacy Help Desk: 800-728-7947

Notice To ProvidersVerify benefits and eligibility at

portal.swhp.org/providerportal or 800-321-7947

Please send claims and related correspondence to:Scott & White Health Plan | Availity Payer ID 88030Attn: Claims PO Box 21800, Eagan, MN 55121-0800

254-298-3000 or 800-321-7947


Sample ID card for groups with out-of-area coverage. Notice the MultiPlan and PHCS logos.

Large Group HMO and HMO-POS members will have the Scott & White Care Plans logo instead.

Please contact Scott & White Health Plan Health Services Departmenttoll free at 844-633-5322 for pre-authorization requests (includingBehavioral Health). If you require inpatient admission following anemergency, please notify SWHP within 48 hours of emergency services.

Find a provider at MyCigna.com... Nurse Advice Line: 877-505-7947Members call: 800-321-7947 ..Member/Pharmacist Help Line: 800-325-1404


Medical Claims Address:... Pharmacy Claims Address:Scott & White Health Plan | Availity Payer ID 88030.... Connecticut General Life Insurance CompanyAttn: Claims PO Box 21800... Pharmacy Service Center | P.O. Box 188053Eagan, MN 55121-0800..... Chattanooga, TN 37422-8053Benefits are not insured by Cigna or affiliates


AWAY FROM HOME CARE


Large Group with Cigna

GROUP PRODUCTS

Certain group products include an added level of network access through Cigna. ID cards for those members display the logo of Scott and White Health Plan or the applicable insuring subsidiary, as well as the Cigna logo.

For more information about commercial group products and benefits, visit swhp.org/plandocs.

RX PCN: Primary:Specialist:Urgent:

JOHN DOE

RX BIN:

RX Group:

PPOTIER 1 / TIER 2:



*BSWH pharmacies. ** Other contracted pharmacies

RX Generic:Emergency:

BSWH EmployeeMedical Plan

$75 / $100

SWHP Group No.:

...IRX

$35* / $50**

$35 / $70

$250 waived if admitted

...SWPASO $60 / $100

RX Preferred:

...610011

$3* / $10**

Cigna PPO

CIGNA Group No. 0198636"S"

NetworkPlease contact Scott & White Health Plan Health Services Departmenttoll free at 866-384-3488 for pre-authorization requests (including BehavioralHealth and Second Opinions). If you require inpatient admission following anemergency, please notify SWHP within 48 hours of emergency services.

Find a provider at bswh.swhp.org Patient Advisory Nurse: 800-724-7037Members call: 844-843-3229....

Pharmacy Help Desk: 800-728-7947BSWQA HealthAccess:.......844-279-7589


Please send claims and related correspondence to:Scott & White Health Plan | Availity Payer ID 88030Attn: Claims PO Box 21800, Eagan, MN 55121-0800Benefits are not insured by Cigna or affiliates


AWAY FROM HOME CARE

Large Group with Employer LogoID cards for select employer groups may include the employer’s company logo.

Primary:Specialist:

12345678900JOHN DOE Issue Date:

Group No.:



FrontBottomLine1FrontBottomLine2www.ers.texas.gov

Urgent:

TDI

Variable07

Member No.:

Emergency:Variable08

Variable04Variable03

Variable06

Variable09

RX BIN: Variable11RX PCN: Variable12RX Group: Variable13RX Copay: Variable13

BSW PreferredHMO Network


Plan information/provider list: ers.swhp.org Nurse Advice Line: 877-505-7947Customer Service: 800-321-7947 ..OptumRx Help Desk: 855-205-9182




Employees RetirementSystem of Texas

http://swhp.org/en-us/plandocs


Baylor Scott & White Health Employee Plan

For more information about Commercial HMO Plans and their benefits, visit http://swhp.org/en-us/plan-types-explained.

BSW HEALTH EMPLOYEE PLAN

Baylor Scott & White Health employees can select a PPO, EQA or SEQA plan. The PPO is a tiered network with access to Cigna providers available in the third tier.

RX PCN:In NetworkPrimary:Specialist:

..........JOHN DOE

RX BIN:

RX Group:

EQA




RX Generic


SWHP Group No.:

...IRX

$35* / $50* *Emergency:

...SWPASO

RX Preferred: $250 waived if admitted

...610011


Find a provider at bswh.swhp.org Patient Advisory Nurse: 800-724-7037Members call: 844-843-3229.... Pharmacy Help Desk: 800-728-7947

BSWQA HealthAccess:.......844-279-7589




..................Urgent/Emergency Services Only

RX PCN:In NetworkPrimary:Specialist:

..........JOHN DOE

RX BIN:

RX Group:

SEQA




RX Generic:U rgent:


SWHP Group No.:

...IRX

$25* / $50**E mergency:

...SWPASO

RX Preferred: $250 waived if admitted

...610011

$3* / $5**







..................Urgent/Emergency Services Only

RX PCN: Primary:Specialist:Urgent:

..........JOHN DOE

RX BIN:

RX Group:

PPOTIER 1 / TIER 2:




RX Generic:Emergency:


$75 / $100

SWHP Group No.:

...IRX

$35* / $50**

$35 / $70

$250 waived if admitted

...SWPASO $60 / $100

RX Preferred:

...610011

Cigna PPO

CIGNA Group No. 0198636"S"

NetworkPlease contact Scott & White Health Plan Health Services Departmenttoll free at 866-384-3488 for pre-authorization requests (including BehavioralHealth and Second Opinions). If you require inpatient admission following anemergency, please notify SWHP within 48 hours of emergency services.




Please send claims and related correspondence to:Scott & White Health Plan | Availity Payer ID 88030Attn: Claims PO Box 21800, Eagan, MN 55121-0800Benefits are not insured by Cigna or affiliates


AWAY FROM HOME CARE

Urgent:


Scott and White Health Plan offers HMO and PPO Medicare Advantage plans. These plans provide all the benefits of Original Medicare but may include extra benefits such as vision, hearing, fitness, and dental, depending on the plan.

For more information about Medicare Advantage Plans and their benefits, visit advantage.swhp.org.

MEDICARE ADVANTAGE PRODUCTS

HMO Medicare Advantage (no Rx)

HMO Medicare Advantage with Prescription Drug Plans

PPO Medicare Advantage with Prescription Drug Plans

RX BIN: Group No.:PCP/Spec:

12345678900JOHN DOE

Health Plan:

RX PCN:

HMO

Please have this card available at all times. This card is for identification purposes onlyand does not guarantee membership or coverage.

RX Group: ER/Urgent:/

Member No.:

/

(80840) 7588667718

CMS H8142_

MEMBERS - Call 866-334-3141 for services requiring prior authorization.Emergency and urgently needed services are covered outside the plan servicearea (but not outside of the U.S.). If you require inpatient admission following an

Self-Service:OptumRx Help Desk:24-Hour Nurse Advice:Virtual Care:

866-334-3141 (TTY: 711)portal.swhp.org844-230-9357877-505-7947MyBSWHealth.com or MyBSWHealth app

PROVIDERS - For benefits and eligibility, visit https://portal.swhp.org/providerportal.For assistance, call 800-655-7947.Please send medical claims and related correspondence to:SCOTT AND WHITE HEALTH PLAN - Attn: CLAIMSPO Box 21800Eagan, MN 55121-0800

emergency, please notify SWHP within 48 hours of emergency services.

Customer Service:


12345678900JOHN DOE

Health Plan:

RX PCN:

HMO



Member No.:

/RX Copay:

(80840) 7588667718

CMS H8142_






Customer Service:


12345678900JOHN DOE

Health Plan:

RX PCN:

PPO



Member No.:

/RX Copay:

(80840) 7588667718

CMS H2032_


Medicare limiting charges apply.





Customer Service:

http://advantage.swhp.org/en-us/


Individual and Family

NOTE: The Individual and Family HMO and EPO plans are offered only off the Federally Facilitated Marketplace (“Exchange”).

HMO BRONZE 7500 EPO BRONZE 7500

RightCare provides STAR Medicaid services plus extra member benefits, such as a baby shower for new mothers; free car seats, baby monitors and strollers; and gift cards for healthy outcomes.

For more information about RightCare STAR Medicaid, visit rightcare.swhp.org.

RightCare STAR Medicaid

STAR/MedicaidMember Name:Member ID#: 999911606

01/01/2015

SW9Card6 A Sampl e

PCP: PCPNamePCP Phone #: (555) 555-5555

Customer Service Phone #: 1-855-TX-RIGHT(1-855-897-4448)

RCSWHP 6145

INDIVIDUAL and MEDICAID PRODUCTS


123456789JOHN DOE

Group No.:

RX PCN:

Issue Date:



TDI

RX Group: Urgent:

EPO

Contract No.:

Emergency:

EPO Network - Indiv/Family

RX Copay:


12345678900JOHN DOE

Group No.:

RX PCN:

Issue Date:



TDI

RX Group: Urgent:

HMO

Member No.:

Emergency:

HMO Network - Indiv/Family

RX Copay:











Short Term

Group No.:Issue Date:Emergency:Urgent:

Contract No.:

RX BIN:

RX Copay:PPO



Above copays are for in-network benefits. For questions concerning out-of-network benefits,additional copays, and for membership eligibility verification, please visit swhp.org.

This card is for identification purposes only and does not guarantee membership or coverage.

RX PCN:

Short Term Medical Plan

JOHN DOE

RX Group:

123456789

06570000

®

PLEASE HAVE THIS CARD AVAILABLE AT ALL TIMES

Notify Insurance Company of Scott & White (ICSW) within 48 hoursafter an emergency requiring hospitalization. Out-of-network benefitswill be paid based upon ICSW's allowed amount.

NOTICE TO ALL PROVIDERS - To verify benefit and eligibility information,visit https://portal.swhp.org/providerportal or call 800-321-7947.

Pharmacy Assistance: 800-728-794724 Hour Nurse Advice Line: 877-505-7947

Please send claims and related correspondence to:INSURANCE COMPANY OF SCOTT AND WHITE

PO Box 21800 Eagan, MN 55121-0800800-321-7947

http://rightcare.swhp.org/en-us/

provider reference guide...2020 provider reference guide group products no referrals are required in...

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