Prior to issuing a medical necessity denial in response to an authorization request for medical services, a representative calls the treating provider and offers to schedule a peer-to-peer review. The review should take place prior to issuance of the denial. Baylor Scott & White Health Plan (BSWHP) requests providers to promptly respond to the peer-to-peer request in order to ensure a timely and effective review of authorization requests for medical services.
To increase communication with BSWHP providers across all lines of business, we would like to take this opportunity to outline the regulatory requirements for peer-to-peer or P2P.
Self-Insured (regulated by ERISA): ERISA guidelines do not require P2P for self-insured policy holders, however the provider will be contacted to allow submission of additional information prior to rendering a decision.
Medicare, Commercial (regulated by TDI), FEHB (regulated by OPM), Medicaid: Before a denial is issued, the provider of record is afforded a reasonable opportunity to discuss the services under review during normal business hours. Providers are required to respond in a timely manner to accept the opportunity.
Contact Customer Service at 254.298.3000 if you have any additional questions.
Effective June 1, 2017, the BSWHP Health Services Department (HSD) no longer accepts retroactive authorization requests. If a service requires prior authorization and the authorization is not obtained prior to the service being rendered, the claim for the service will be denied.
The BSWHP HSD will continue to accept retroactive notifications for the limited services that require one. A reference number will be provided for the notification. For more information, please do not hesitate to contact the BSWHP HSD at 888.316.7947.
All BSWHP non-contracted provider requests for prior authorization are processed by Cigna.
Please take the following steps to ensure your request is processed in a timely manner:
- You MUST FIRST verify benefits and eligibility with BSWHP by phone. Call 844.769.3994 and speak to a customer advocate.
- When verification is complete, you may have the advocate transfer you directly to Cigna, OR you may contact Cigna at 866.494.4872 to determine prior authorization requirements and initiate prior authorization requests.
Medical Authorization Requests
Prior Authorization Requirements (powered by eviCore)
Prior authorization lists
For any item on the prior authorization list, be sure to complete a prior authorization request. The forms are based on the Texas Department of Insurance (TDI) Standardized Prior Authorization Form.
Texas House Bill 3459
The process for obtaining prior authorization is changing for members in group and individual health benefit plans (not self-funded), in compliance with Texas House Bill 3459. Starting Oct. 1, a list of services for which you will no longer need prior authorization for Texas state regulated plans will be on your Provider Portal and will be updated routinely as necessary. To receive notification via mail or email instead, click the link below and complete the form.
BSWHP prior authorization forms
Prior authorization requests for services and drugs obtained under the medical benefit (i.e. drug will be billed on a medical claim by a provider) are processed by BSWHP Health Services Division.
Health Services Department (HSD) does not process prior authorization requests for drugs obtained under the pharmacy benefit (i.e. prescription drug benefit). The submission process and forms below apply only to requests for medical benefit coverage of services and drugs.
For more information regarding prior authorization submission process for drugs obtained under the pharmacy benefit, visit Drug Requests - Prior Authorizations, Exceptions and Appeals.
Health Services Division accepts medical benefit prior authorization and peer-to-peer requests during regular business hours (8 AM to 5 PM) and any time after hours in the following ways:
Annual PA approval and denial rates
Statistics regarding Prior Authorization approval and denial rates for requested services.
Each list includes statistics on:
- Prior authorizations approved
- Prior authorizations denied
- Adverse determinations overturned on internal appeal
- Total number of prior authorizations
Medical Management Forms
Continuity of Care - Transition of Care Policy and Forms
Medical Coverage Policies
Choose from the following policy topics below.
View policy documents
Medical Coverage Policies
(in alphabetical order)
Archive: Medical policy and prior authorization update notices
We reimburse medically necessary surgical services. See the appropriate links below to download more
information about specific policies.
Quality Improvement: Clinical Guidelines
An effective approach to healthcare requires a clinical touch
In the face of escalating healthcare costs and rapid medical advancements, we're continually evaluating and evolving our policies. We use clinical data, industry-accepted guidelines and other sources to inform our quality measurement procedures.
We're as equally committed to supporting transparency, which helps us and our network of providers, make informed decisions regarding the healthcare of our members.
Read more about our clinical programs and review processes.
BSWHP's Case Management Program is included in health plan coverage as an added benefit for our members. The program is at no cost to your patient and completely voluntary. Your patient may opt in or out at any time.
Case Management Program provides:
- Coordination to bridge gaps in care for needed treatment, services and/or equipment
- Empowerment towards self-management of chronic diseases/conditions
- Specialized management options based on diagnoses, medications and health status including pregnancy and behavioral health
- Guidance and advice on the healthcare system and patient benefits
- Assistance with coordination of referrals and authorizations
- Referrals to community resources to alleviate social determinant of health barriers
What to expect after referring to Case Management:
A member of the Case Management team will call your patient, offer Case Management and attempt to complete a comprehensive health assessment. Any needs or opportunities for assistance identified during the assessment will be utilized to develop an individualized plan of care with your patient. Our staff will continue to work with you and your patient until the goals are met, the member's coverage terminates, the member remains unreachable or they decline to continue.
To refer your patient for the Case Management program, please email CaseManagement@BSWHealth.org.
Complex Case Management
BSWHP seeks to assist members who have experienced a critical event or diagnosis that requires extensive use of resources. Personalized case management by an assigned Complex Case Manager facilitates a comprehensive, multi-disciplinary approach to promote member autonomy and enhance the continuity of care and the member's quality of life. By combining advocacy with open communications and resource management, we're able to promote cost-effective care interventions and outcomes. Case managers help patients with chronic illnesses, catastrophic illnesses or injuries get the most out of their healthcare.
Our program helps transfer patients to specialized treatment facilities, ensuring their care needs are met. Patients, with support from their physician and family members, set goals that roadmap their recovery to a healthier status. The scope of services provided include:
- Initial health assessment status
- Case Management program education
- Member-specific care plan development
- Care plan progress reassessments and evaluation of adherence
- Regularly scheduled case manager contact, based on acuity
- Transition of care support between inpatient to other facilities or home
- Assistance in navigating and collaborating with providers and community resources
We believe in a better, healthier life for all. We work with members to help with their chronic illnesses or conditions through the development of a collaborative treatment plan with their primary care provider and ensure they are monitoring their conditions.
Our predictive modeling tool analyzes claims and pertinent data to:
- Identify members with existing conditions
- Establish current risk levels
- Predict future risks
Members considered medium to high risk are assigned a dedicated clinician who helps identify personal goals and create a plan for self-management. Through education, members are empowered to take control over the status of their health. For members in need of behavioral health services, our conditional guidance program identifies and addresses psychosocial issues. As they demonstrate a readiness to change, we guide members to make the behavior modifications necessary to achieve goals and improve health.
Utilization Management Program
Our Utilization Management (UM) Program ensures members receive services in a timely, appropriate and cost-effective manner.
Utilization Management Program Description
The UM Program Description details the decision-making process we use across our Commercial, Self-Insured and Medicare lines of business. The program is evaluated and updated annually by senior management, approved by the Quality Improvement Committee with recommendations from the Utilization Management Committee.
As a physician/health professional who practices in Texas, you have the opportunity to strengthen your provider/patient relationships by offering telemedicine services.
Telemedicine and telehealth services are covered for fully insured commercial PPO, EPO and HMO/POS plans in accordance with Texas Insurance Code, Chapter 1455. Reimbursement is based upon rates for equivalent face-to-face services. Medical policies, benefits and eligibility are also determining factors for reimbursement.
BSWHP provides general reimbursement information and fee schedule information based upon coding. Click on the Provider Login link or Create an Account to view this information. You may also request it from your Provider Representative or by calling BSWHP.
About Our Hospitalization Procedures for Members
We follow a review process for all emergency, elective and scheduled hospital admissions.
Hospital admission or observation status
Members are covered for life-threatening urgent and emergency care at any time in any facility. If any member requires observation or hospital admission, notify us within 24-48 hours of admission to receive consideration of BSWHP coverage for the stay.
Call our Health Services Department at 254.298.3088 or 888.316.7947 8 AM to 5 PM weekdays.
Call our Health Services Department at 254.724.2111 after-hours, weekends and holidays
When calling, have the following ready:
- Member Name or membership number from BSWHP ID Card
- Day and time of admission or observation
- Route of admission (ER, urgent, scheduled clinic admit)
- Facility name and telephone number
- Admitting or attending physician or provider
- Telephone number for physician(s) or utilization review (U.R.) department
- Admitting diagnosis
- Scheduled or performed procedure(s)
Our Health Services Department (HSD) staff provides a confirmation number for billing purposes to the facility. This indicates that admission or observation has been called in within the authorized time frame. This is not an authorization for payment. You'll be provided member benefits and approved length-of-stay (LOS). The HSD Utilization Management Clinician may need to obtain a report from the physician, utilization review or case management department of the facility prior to determining BSWHP coverage
All elective and scheduled admissions for selected procedures must be pre-approved by BSWHP Medical Director(s) through the appropriate BSWHP Authorization Form.
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 BSWHP internally developed criteria of medical necessity, as determined by Plan Medical Director(s). The 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 we do not authorize an extension of hospital days based on submitted medical justification, those days will not be paid.
Retrospective (post-service) review
It is noted that the majority of determinations made by BSWHP are related to benefit coverage interpretations according to the Evidence of Coverage (EOC) and/or Standard Plan Document (SPD) and do not involve issues of medical necessity or appropriateness. Other decisions about medical necessity or appropriateness are made by the BSWHP Medical Director(s) with input from the treating clinical Practitioners as appropriate. BSWHP benefit determinations are related to payment for care or services based upon input from the Practitioner/Provider and according to the terms of the benefit contract.
HSD, delegated reviewers or BSWHP Medical Nurse Auditor(s) conduct Retrospective (Post-Service) reviews on cases not reviewed during the inpatient or concurrent review process. Cases may be missed due to the type or frequency of test or procedure when medical records were unavailable or the patient was admitted and discharged from a facility or provider's care before a report could be obtained or records reviewed (i.e., situations in which the case and/or medical records have never been reviewed by BSWHP due to circumstances beyond our control).
This does not include subsequent review of services for which prospective or concurrent reviews were previously conducted. When retrospective (Post-Service) review is performed, the review is based on written screening criteria (InterQual® or internally developed BSWHP Screening Criteria) established and annually updated with appropriate involvement from physicians (practicing physicians) and other healthcare providers. The HSD, delegated reviewer or Medical Nurse Auditor reviews any potential issues regarding medical necessity or appropriateness with the Plan Medical Directors(s). No medical necessity denials are issued without Medical Director review and approval. If any denial is issued, appeal rights are provided to both the Member and the Practitioner or Provider.
Some retrospective reviews may be conducted to collect data for health or medical care evaluation studies. These are not related to the payment of claims.
For information or clarification, contact our Health Services Department at 254.298.3088 or 888.316.7947.
Emergency Observation and Inpatient Services
BSWHP/BSWIC members are covered for life-threatening urgent and emergency care at any time in any facility. If any member requires observation or hospital admission, notify us as soon as possible post-stabilization, within 24-hours of admission to receive consideration of BSWHP coverage for the stay. If requesting inpatient level of care, include a summary of clinical presentation to support the request. An assigned BSWHP Utilization Review nurse reviews the request based on a combination of evidenced-based clinical guidelines, NCD/LCD and/or medical policy and responds to the admission request within 24-48 hours. If approved, concurrent review between the hospital case manager and the BSWHP Utilization Review nurse should occur during admission stay.
Services Provided by Out-of-Network or Non-contract Providers
BSWHP/BSWIC provides a variety of benefit plans. Some lines of business (e.g. PPO/POS) have an out of network benefit. If the member stays in an out of network facility, the member may be responsible for the remainder of the bill regardless of the authorization. To minimize balance-billing costs, we encourage you to call us for assistance in transferring to an in-network facility.
Provider Network Management Policies