Providers
Scott and White Health Plan acquires FirstCare Health Plans
Effective Jan. 1, 2019, Scott and White Health Plan, part of Baylor Scott & White Health, acquired FirstCare Health Plans. The acquisition allows two provider-owned health plans to come together to create a more comprehensive and sustainable insurer with a driving focus on enhancing the customer experience through advanced technology.
For more information, visit FirstCare.com/SWHP.
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Contact Your FirstCare Provider Relations Team
Our Provider Relations Team is here for you. If you have questions or need support, view our Provider Relations Representative territory map to find contact information.
For additional assistance and questions, call 800-431-STAR (7798) or 877-639-CHIP (2447).
Quality Improvement Subcommittee (QIS)
The Quality Improvement Subcommittee (QIS) develops, reviews and approves clinical programs and guidelines, studies and other clinical activities related to the health care services provided to FirstCare members.
The QIS adopts evidence and approves clinical criteria on an annual basis.
Specific functions and responsibilities
- Provide regular clinical measurement oversight
- Identify and monitor key quality indicators that measure performance against clinical practice guidelines, external benchmarks and internal targets (HEDIS)
- Assist with review of clinical aspects of the Quality Improvement (QI) program, work plan, and the Care Management program Recommend new opportunities or changes in current programs and interventions to improve clinical care and service
- Assist with development, review and maintenance of clinical policies and procedures
- Review and analyze potential quality of care issues if required
- Review, assess, and recommend internal utilization management practices
- Approve the criteria used to review authorization decisions at least annually
- Review and approve the Utilization Management (UM) program description
- Evaluate utilization functions including the assessment and analysis of utilization statistics, management guidelines, referral trends, ambulatory treatment patterns, inpatient monitoring processes and the effectiveness of discharge planning programs
Committee Structure
The membership is comprised of the following:
- Chief Medical Officer
- Vice President of Quality
- Medical Director
- Vice President of Health Services
- Vice President of Pharmacy Services
- VP Government Programs
- Vice President of Network Development
- Director Quality Improvement and Clinical Analytics
- Director, Customer Advocacy
- Director Medicaid Operations
- Director Medicare
- Director Grievance and Appeals
- BSWH Quality Alliance Physician Representative
- Specialty Care representatives
- Primary Care representatives
Quorum
The committee meets monthly and the quorum defined as more than one half of the committee membership.
Meetings may be held without a quorum, but voting may not take place.
Prior Authorization
Prior authorization is sometimes called pre-certification or pre-notification. Prior authorization verifies whether medical treatment that is not an emergency is medically necessary. It also determines if the treatment matches the diagnosis and that the requested services will be provided in an appropriate setting. During prior authorization, Baylor will also verify if the Member has benefits.
Prior authorization DOES NOT guarantee payment. Even if a Provider obtained the required prior authorization, Baylor must still process a Providers claim to determine if payment will be made. The claim is processed according to:
- Eligibility
- Contract limitations
- Benefit coverage guidelines
- Applicable State or Federal requirements
- National Correct Coding Initiative (NCCI) edits
- Texas Medicaid Provider Procedures Manual (TMPPM)
- Other program requirements, as applicable
Prior Authorization Requests: Essential Information & Supporting Clinical Documentation
Providers must submit the Prior Authorization Request Form. The form must include the following information to initiate the prior authorization review process:
- Member name
- Member date of birth
- Member number
- Requesting provider name
- Requesting providers National Provider Identifier (NPI)
- Rendering providers name
- Service requested:
- Current Procedural Terminology (CPT)
- Healthcare Common Procedure Coding System (HCPCS)
- Current Dental Terminology (CDT)
- Service requested start and end date(s)
- Quantity of service units requested based on the CPT, HCPCS, or CDT requested
- Requesting Providers Dated Signature
Please note any prior authorization requests missing essential information will not be processed and a new request will need to be submitted. To avoid delays in authorization or administrative denials, Providers are encouraged to submit sufficient documentation to validate the medical necessity for the services being requested. This may include, current progress notes, history and physical, radiology or laboratory results, consult notes/reports, treatment plans showing progress to goals (e.g. therapy requests), or similar medical record documentation to illustrate medical necessity.
Supporting Clinical Documentation
Lack of Information
When BSWH receives a request for prior authorization and the request does not contain complete clinical documentation and/or information:
- BSWH will notify the Member by letter that an authorization request was received but cannot be acted upon until BSWH receives the missing documentation/information from the requesting Provider. The letter will include the following information:
- A statement that BSHW has reviewed the PA request and is unable to make a decision about the requested services without the submission of additional information.
- A clear and specific list and description of missing/incomplete/incorrect information or documentation that must be submitted in order to consider the request complete.
- Timeline for the provider to submit the missing information.
- Contact information and modes of communication for provider inquiry if necessary.
- BSWH will contact Provider via fax or phone and request documentation for completion of the medical necessity review within three business days of BSWH receipt of request (where applicable).
- If BSWH does not receive the documentation/information by the end of the third business day of our request to the requesting Provider, the request will be submitted to the Medical Director no later than the seventh business day after receipt of request (where applicable).
- BSWH will render a decision no later than the tenth business day after the request received date.
Provider Relations
If you have provider-related inquiries, please contact our Provider Relations department:
You may also call the Provider Relations representative in your region, 8 a.m. to 5 p.m. weekdays:
- Abilene area: 254-298-3064
- Amarillo area: 800-239-5650
- Lubbock area: 806-784-4380
- All other areas: 800-431-7737
Specialty Providers Referrals
Referrals are needed to see most FirstCare specialty provider. A referral is an approval from a member's PCP for them to get specialty care and follow up treatment. If member's receive services from a specialist without their PCP's referral, or if the specialist is not a FirstCare provider, they might be responsible for the bill. There are some services members can receive without seeing their PCP first. These include:
- 24-hour Emergency Care (if you feel you have a true medical emergency)
- Routine Vision Care
- Dental Services (for children)
- OB/GYN Care
- Family Planning Services and Supplies
- Behavioral (Mental) Health and Substance Abuse Services
- Texas Health Steps
For more information, call 800-431-STAR (7798) or 877-639-CHIP (2447).
Member Rights & Responsibilities
STAR & CHIP Provider Training
Provider Advisory Group
FirstCare will conduct quarterly Provider Advisory Groups with network providers to address any needs and concerns from the provider population. The Provider Advisory Group will include acute care, pharmacy providers, Provider Services, Medicaid Operations staff, and the FirstCare Medicaid Medical Director. We will review phone calls and complaint logs to determine patterns of concern that need to be addressed. We will solicit providers for participation after they have completed the contracting and credentialing process. Provider feedback will be requested on the Provider Manual, newsletters and the FirstCare website. We will utilize technology to engage providers across the service area. For more information on Provider Advisory Groups, please contact FirstCare Provider Relations:
- Abilene area - 254-298-3064
- Amarillo area - 800-239-5650
- Lubbock area - 806-784-4380
- All other areas - 800-431-7737
Provider Claim Appeal
A claim appeal is a request for reconsideration of payment for a previously adjudicated claim. Providers who are filing an appeal of a claim decision will need to submit a copy of the Explanation of Benefits (EOB) page showing the claim in question, a claim form and other supporting documentation including the reason for the appeal. Providers should submit one copy of the EOB for each claim to be appealed and circle which claim is being appealed. The reason for the appeal or reconsideration request may be written on the EOB or described in a separate document. All information should be printed on a single side of the copy. If the original claim was denied for incorrect information, a new CMS 1500 or UB-04 with the corrected information should be submitted as a corrected claim. Appeals must be written and submitted within 120 days from the date of disposition, which is the date on the Remittance Advice. FirsttCare will adjudicate all appeals within 30 days of receipt of the appeal.
- Submit all correspondence to:
FirstCare Health Plans
P.O. BOX 211342
Eagan, MN 55121-1342
- Electronic submission through provider portal: my.firstcare.com/Web/
Note: Any complaints or appeals received at the wrong address will be returned to the sender.
The preferred method for claims appeals submission is mail or electronic submission. Non-preferred method: contact 800-431-7798; email claimappealsprovider@BSWHealth.org; fax 512-597-3203
