2021 Provider Reference Guide - SWHP.org

1 PR_RefGuide-20212021 Provider Reference Guide2021 Provider Reference Guide HELPFUL PLAN INFORMATION Commercial & MedicareMedicaidWebsite ResourcesProvider Home Provider and Search #/searchProvider Home and Search #/searchClaims/ eligibility VerificationProvider PortalPlease visit our website at the following to determine the appropriate portal for claims and eligibility verification: Verification Line (IVR Line): or Provider Portal Customer Service855-TX-RIGHT ( ) Claims FilingElectronic Clearinghouse AvailityPayor ID: 94999 Initial Filing Deadline 95/365 (Commercial/Medicare) days from date of service Corrected Filing Deadline 90 (Commercial) days from the date of deter-mination on the initially filed clean claim 365 (Medicare) days from the date of servicePaper Claims Filing AddressScott and White Health PlanATTN: Claims Review Box 21800 Eagan, MN 55121-0800 BSWHP is transitioning commercial business to a new claims system in a phased approach.

2 If your group has transitioned to the new claims system, your claims should be sent to: Scott and White Health Plan BOX 211342 Eagan, MN 55121-1342 More Clearinghouse Change HealthcarePayor ID: 74205 Initial Filing Deadline95 days from date of serviceCorrected Filing Deadline 120 days from the date of dispositionPaper Claims with DOS prior to 11/1/2019 RightCare from Scott and White Health Plan Attn: Claims Appeals MS-A4-144 1206 West Campus Drive Temple, Texas 76502-9915 Paper Claims with DOS on/after 11/1/2019 Scott and White Health Plan ATTN: RightCare PO BOX 981727 El Paso, TX 79998-1727 More Information Change Healthcare Customer Service 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 55121-0800 Redetermination Submission Paper: : #/login (Preferred Method)Filing Deadline 120 days from the original determination date 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 76502-9915 Claims with a DOS on/after 11/1/2019 should be sent to:Scott and White Health PlanATTN: RightCarePO BOX 981727El Paso, TX 79998-1727 Electronic submission through Provider portal: 2021 Provider Reference Guide Commercial & MedicareMedicaidPayment MethodsProviders will be reimbursed through a Virtual Credit Card (VCC) unless they opt opt out of VCC, select Automatic Clearinghouse (ACH) or Electronic Funds Transfer (EFT), contact.

3 ECHO Health register with ECHO Health click will receive Virtual Credit Card unless they enroll in EFT by registering with ECHO register with ECHO Healthclick RequestsMail Refund RequestsScott and White Health PlanATTN: Claim RefundsPO Box 840523 Dallas, TX 75284-0523 More Refund RequestsScott and White Health PlanATTN: RightCarePO Box 841476 Dallas, Texas 75284-1476 More information Benefit Prior AuthorizationPA List and Request Form BSWHP Health Services or look-up tool #/login (Link contains information regarding eviCore and Oncology Analytics)PA List and Request Form PA Portal Request Management Phone: Fax: Behavioral Health Management Phone: Fax: ResourcesPharmacy Services Authorization Forms Prescription Drug Lists Notifications and Prior Providers Pharmacy Contact InformationProvider Relations Phone: or Fax: Customer Advocacy Commercial: Medicaid: Medicare: (TTY 711)HELPFUL PLAN INFORMATION 2021 Provider Reference Guide GROUP PRODUCTS No referrals are required in any of our networks.

4 HMO and EPO plans offer in-net-work 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).Our commercial group products include HMO, HMO-POS, PPO, EPO, HDDP, and Out-of-Area options for small, large, and self-funded Products: HMO & HMO-POSPHARMACISTS ONLYJOHN SAMPLESMEMBER IDDEPENDENTSSUBSCRIBERIN-NETWORK PLAN BENEFITSJANE SAMPLEJIMMY SAMPLEA dult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:/Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:/Emergency Room:Emergency Room:Emergency Room:Emergency Room:Med Deductible:Med Deductible:Med Deductible:Med Deductible:Rx:Rx:Rx:Rx:BIN:BIN:BIN:BIN:6 10011 PCN:PCN:PCN:PCN:IRXGRP:GRP:GRP:GRP:SWPBS WCPHelp Desk: 855-205-9182 OptumRx PHARMACISTS ONLYJOHN SAMPLESMEMBER IDDEPENDENTSSUBSCRIBERIN-NETWORK PLAN BENEFITSJANE SAMPLEJIMMY SAMPLEA dult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:/Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:/Emergency Room:Emergency Room:Emergency Room:Emergency Room:Med Deductible:Med Deductible:Med Deductible.

5 Med Deductible:Rx:Rx:Rx:Rx:BIN:BIN:BIN:BIN:6 10011 PCN:PCN:PCN:PCN:IRXGRP:GRP:GRP:GRP:SWPBS WCPHelp Desk: 855-205-9182 OptumRx Group:Group #:Network: BSW PLUS HMOB enefit Effective Date:Group:Group #:Network: BSW PLUS HMOB enefit Effective Date:CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:844-633-5325844-633-5325844-633- 5325844-633-5325 PROVIDERSFOR MEMBERSE lectronic Claims:Electronic Claims:Electronic Claims:Electronic Claims:Availity: 94999 Paper Claims:Paper Claims:Paper Claims:Paper Claims:Scott and WhiteHealth PlanATTN: ClaimsPO Box 211342 Eagan, MN 55121-1342 Prior Authorization:Prior Authorization:Prior Authorization:Prior Authorization:Visit the Provider portalFax: 800-626-3042 Phone: 866-384-3488 Provider Portal: Provider Portal: Provider Portal: Provider of this card or obtaining precertification doesnot guarantee coverage or payment for the service orprocedure Information:Important Information:Important Information:Important Information:n a medical emergency, call 911 or go to the nearest emergency facility.

6 Customer Service: 844-633-5325 (TTY: 711) 24/7 Nurse Line: 877-505-7947 Self-Service Portal: avoid out-of-network costs and Provider balance billing, find a Provider at Issue Date:Card Issue Date:Card Issue Date:Card Issue Date:04/29/2021 I T CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:844-633-5325844-633-5325844-633- 5325844-633-5325 PROVIDERSFOR MEMBERSE lectronic Claims:Electronic Claims:Electronic Claims:Electronic Claims:Availity: 94999 Paper Claims:Paper Claims:Paper Claims:Paper Claims:Scott and WhiteHealth PlanATTN: ClaimsPO Box 211342 Eagan, MN 55121-1342 Prior Authorization:Prior Authorization:Prior Authorization:Prior Authorization:Visit the Provider portalFax: 800-626-3042 Phone: 866-384-3488 Provider Portal: Provider Portal: Provider Portal: Provider of this card or obtaining precertification doesnot guarantee coverage or payment for the service orprocedure Information:Important Information:Important Information:Important Information:n a medical emergency, call 911 or go to the nearest emergency facility.

7 Customer Service: 844-633-5325 (TTY: 711) 24/7 Nurse Line: 877-505-7947 Self-Service Portal: avoid out-of-network costs and Provider balance billing, find a Provider at Issue Date:Card Issue Date:Card Issue Date:Card Issue Date:04/29/2021 I T MPL0001 SMPL0001S2021 Provider Reference Guide For more information about commercial group products and benefits, visit Group Products: PPOCUSTRVICE:CUSTRVICE:CUSTRVICE:844-633 -5325844-633-5325844-633-5325 PROVIDERSFOR MEMBERSE lectronic Claims:Electronic Claims:Electronic Claims:Electronic Claims:Availity: 94999 Paper Claims:Paper Claims:Paper Claims:Paper Claims:Scott and WhiteHealth PlanATTN: ClaimsPO Box 211342 Eagan, MN 55121-1342 Prior Authorization:Prior Authorization:Prior Authorization:Prior Authorization:Visit the Provider portalFax: 800-626-3042 Phone: 866-384-3488 Provider Portal: Provider Portal: Provider Portal: Provider of this card or obtaining precertification doesnot guarantee coverage or payment for the service orprocedure Information:Important Information:Important Information:Important Information:n a medical emergency, call 911 or go to the nearest emergency facility.

8 Customer Service: 844-633-5325 (TTY/TDD: 711) 24/7 Nurse Line: 877-505-7947 Self-Service Portal: avoid out-of-network costs and Provider balance billing, find a Provider at Issue Date:Card Issue Date:Card Issue Date:Card Issue Date:04/29/2021 Group Products: Out of AreaPHARMACISTS ONLYG roup:Group #:Network:BenefitEffective Date:JOHN SAMPLESMEMBER IDDEPENDENTSSUBSCRIBERIN-NETWORK PLAN BENEFITSJANE SAMPLEJIMMY SAMPLEA dult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:/Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:/Emergency Room:Emergency Room:Emergency Room:Emergency Room:Med Deductible:Med Deductible:Med Deductible:Med Deductible:Rx:Rx:Rx:Rx:BIN:BIN:BIN:BIN:6 10011 PCN:PCN:PCN:PCN:IRXGRP:GRP:GRP:GRP:SWPBS WICHelp Desk: 855-205-9182 OptumRx BSW PLUS PPOPHARMACISTS ONLYG roup:Group #:Network:Benefit EffBenefit EffBenefit EffBenefit Effective Date:ective Date:ective Date:ective Date:JOHN SAMPLESMEMBER IDDEPENDENTSSUBSCRIBERIN-NETWORK PLAN BENEFITSJANE SAMPLEJIMMY SAMPLEPCP/Spec:PCP/Spec:PCP/Spec:PCP/Spe c:/Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:/Emergency Room:Emergency Room:Emergency Room:Emergency Room:Med Deductible:Med Deductible:Med Deductible:Med Deductible:Rx:Rx:Rx:Rx:BIN:BIN:BIN:BIN:6 10011 PCN:PCN:PCN:PCN:IRXGRP:GRP:GRP:GRP:SWPBS WACAS mall GroupHelp Desk: 855-205-9182 OptumRx BSW PLUS PPO I T PHARMACISTS ONLYG roup:Group #:Network:Benefit EffBenefit EffBenefit EffBenefit Effective Date:ective Date:ective Date:ective Date:JOHN SAMPLESMEMBER IDDEPENDENTSSUBSCRIBERIN-NETWORK PLAN BENEFITSJANE SAMPLEJIMMY SAMPLEPCP/Spec:PCP/Spec:PCP/Spec:PCP/Spe c:/Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:/Emergency Room:Emergency Room:Emergency Room:Emergency Room:Med Deductible:Med Deductible:Med Deductible:Med Deductible:Rx:Rx:Rx:Rx:BIN:BIN:BIN:BIN:6 10011 PCN:PCN:PCN:PCN:IRXGRP:GRP:GRP.

9 GRP:SWPBSWACAS mall GroupHelp Desk: 855-205-9182 OptumRx PHCSCUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:844-633-5325844-633-5325844-633- 5325844-633-5325 PROVIDERSFOR MEMBERSE lectronic Claims:Electronic Claims:Electronic Claims:Electronic Claims:Availity: 94999 Paper Claims:Paper Claims:Paper Claims:Paper Claims:Scott and WhiteHealth PlanATTN: ClaimsPO Box 211342 Eagan, MN 55121-1342 Prior Authorization:Prior Authorization:Prior Authorization:Prior Authorization:Visit the Provider portalFax: 800-626-3042 Phone: 866-384-3488 Provider Portal: Provider Portal: Provider Portal: Provider of this card or obtaining precertification doesnot guarantee coverage or payment for the service orprocedure Information:Important Information:Important Information:Important Information:n a medical emergency, call 911 or go to the nearest emergency facility. Customer Service: 844-633-5325 Customer Service: 844-633-5325 Customer Service: 844-633-5325 (TTY: 711) 24/7 Nurse Line: 877-505-7947 Self-Service Portal: avoid out-of-network costs and Provider balance billing, find a Provider at Issue Date:Card Issue Date:Card Issue Date:Card Issue Date:04/29/2021 I T CUSTOMER SERVICE:844-633-5325 PROVIDERSFOR MEMBERSE lectronic Claims:Electronic Claims:Electronic Claims:Electronic Claims:Availity: 94999 Paper Claims:Paper Claims:Paper Claims:Paper Claims:eAScott and WhitHealth PlanTTN: ClaimsPO Box 211342 Eagan, MN 55121-1342 Prior Authorization:Prior Authorization:Prior Authorization:Prior Authorization:Visit the Provider portalFax: 800-626-3042 Phone: 866-384-3488 Provider Portal: Provider Portal: Provider Portal: Provider of this card or obtaining precertification doesnot guarantee coverage or payment for the service orprocedure Information:Important Information:Important Information:Important Information.

10 N a medical emergency, call 911 or go to the nearest emergency facility. Customer Service: 844-633-5325 (TTY/TDD: 711) 24/7 Nurse Line: 877-505-7947 Self-Service Portal: avoid out-of-network costs and Provider balance billing, find a Provider at Issue Date:Card Issue Date:Card Issue Date:Card Issue Date:05/05/2021 For emergency or urgent care outside the service area, use:For emergency or urgent care outside the service area, use:For emergency or urgent care outside the service area, use:For emergency or urgent care outside the service area, use: I T CUSTOMER SERVICE:844-633-5325 SERVICE:844-633-5325 Provider Reference Guide 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 more information about Commercial HMO Plans and their benefits, visit Group with CignaPHARMACISTS ONLYJOHN SAMPLESMEMBER IDDEPENDENTSSUBSCRIBERIN-NETWORK PLAN BENEFITS*JANE SAMPLEJIMMY SAMPLEA dult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:Adult PCP/Spec:/Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:Pediatric PCP/Spec:/Emergency Room:Emergency Room:Emergency Room:Emergency Room:Med Deductible:Med Deductible:Med Deductible:le:Rx:Rx:Rx:Rx:BIN:BIN:BIN:BI N:017010 PCN:PCN:PCN:PCN:0519 PAYRGRP:GRP:GRP:GRP:0776717"S" - Cigna Grp#GROUP PRODUCTS ID cards for select employer groups may include the employer s company Group with Employer Logo CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:CUSTOMER SERVICE:844-633-5325844-633-5325844-633- 5325844-633-5325 PROVIDERSFOR MEMBERSE lectronic Claims.