Providers

The QIS adopts evidence and approves clinical criteria on an annual basis. The specific functions and responsibilities of the committee are as follows:

• 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 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, which you can view and download here. The form must include the following information to initiate the prior authorization review process: 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

• Authorization Required List
• Supporting Documentation List
• Medicaid Statistics

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.