Claims and Billing | Baylor Scott & White Health Plan (2024)

Claims and Billing Forms for Providers

How to File a Redetermination

If your claim was denied or you're unhappy with your reimbursem*nt, you may be able to have your claim reprocessed. Currently, we allow redeterminations to be filed for claims based on:

• Filing limits
• Claim check or code editing
• Contracted rate or payment policy
• Coordination of Benefits (COB)
• Data entry error
• Overpayment or underpayment

To file a redetermination, you must:

• Fill out and submit a Provider Claim Redetermination Request Form
• Provide relevant documentation
• Submit the redetermination within 90 days from the date of determination or payment by BSWHP

If there are multiple claims in question, you may provide an Excel spreadsheet that contains the additional information. Attach the spreadsheet to a copy of the request form.

Mail your redetermination or request for adjustment to:

Baylor Scott & White Health Plan
ATTN: Claims Review Dept.
P.O. Box 21800
Eagan, MN 55121-0800

The provider redetermination time limit for receipt of redetermination request is calculated from the date of original denial or Explanation of Payment (EOP). The Provider Claim Redetermination Request Form is processed within 30 days of receipt. To appeal RightCare Medicaid claims, visit RightCare.

How to Submit a Claim

Whether you're filing electronic or paper claims, to avoid having claims delayed, denied or sent back to you for corrections, you'll need to:

• Meet filing deadlines
• Submit clean claims

Filing deadline

All claims must be received in our office within 95 days of the date of service or they will be denied. Coordination of Benefit (COB) claims must be submitted within 95 days of the primary payer's Explanation of Benefits (EOP) date.

For paper claims, the claims receipt date is when your claim reaches our mailroom. Claims received after 2 PM will be considered received the next business day. Please note that members cannot be billed for claims denied by BSWHP for missing filing deadline.

Clean claims

These are claims that we will accept without having to investigate or send back for more information. Clean electronic and paper claims should have:

• Patient's full name
• Patient's date of birth
• Valid BSWHP member identification number (11-digit number)
• Complete service level information
  • Date of Service
  • Industry-standard diagnosis codes
  • CMS defined industry-standard place of service codes
  • Industry-standard procedure codes (e.g., CPT, HCPCs)
  • Charge information and units
• Service provider's name, address and National Provider Identification (NPI)
• Provider's federal tax identification number (TIN)
• Only one servicing provider per claim
• All claim forms must be typed; no handwritten information or corrections
• All required fields completed

For paper claims, we use an imaging system for claims entry. Follow these guidelines to ensure your claim is processed accurately and without delay or rejection. Do not send:

• A fax or a copy of a filled-out form
• A claim that's been torn, taped or crumpled
• A claim that's been stamped or handwritten on

Do not use:

• Correction fluid or tape
• Ink that is fading and/or a color other than black
• Staples
• Highlighters

Claims that are rejected for any of the above listed reasons will be returned to you with a letter explaining the reason for the rejection. These non-clean claims are considered never received and must be corrected and resubmitted within the BSWHP claims filing deadline for reconsideration.

Claim tutorials

Read the following tutorials to learn how to correctly fill in the required fields.

• How to submit a CMS 1500 Claim: Download the guide
• How to submit a UB-04 Claim: Download the guide

Reimbursem*nt

We reimburse medically necessary surgical services and other procedures. For more information, see procedure-specific payment policies.

How to File Electronic Claims

Filing claims has never been faster

Faster responses mean everything in the healthcare industry, so let's reduce the time it takes to process your claims. By filing electronic claims, you can expect:

• More timely payments
• Faster claim status responses
• Lower overhead costs
• More control over claim data accuracy

You may also submit claims through the HIPAA-compliant Availity Web Portal.

About Availity

Availity offers a secure web portal that is simple to use, integrating with software systems typically found in most physician's offices and hospitals around Texas. Availity also delivers information beyond what is available in standard HIPAA transactions.

• Providers submit batch claims for free
• Medical software vendors may charge a fee for installation and maintenance of system enhancements that support claims transmissions
• You must use your National Provider Identifier (NPI) number when submitting claims through Availity so proper provider identification can be made
• When submitting claims, use the Baylor Scott & White Health Plan Payer Number 88030
• Both UB-04 and CMS 1500 claim forms are accepted electronically
• You are strongly advised to review your accepted/rejected reports from Availity daily to determine if any claims were rejected by BSWHP
• Patients' Member Identification Numbers must be complete (and include the two-digit suffix) for a claim to be accepted electronically

Non-contracted providers must fill out an EDI Intake Form before filing claims to BSWHP for the first time. The EDI Intake Form is for our Configuration team to enter your provider information into our claims adjudication system.

For more information, visit Availity or call them at 800.282.4548.

How to File Paper Claims

If you prefer to file claims the old-fashioned way, we do accept paper claims. This will take longer to process than electronic claims. You're expected to follow Texas Department of Insurance (TDI) requirements, as well as meet our requirements for filing claims.

To avoid having your claims delayed, sent back or denied, please be sure to review our submission guidelines and tutorials and send your correspondence by type either to the Paper Claims Address or to the Claim Refunds Address posted below, as appropriate.

For your convenience, we provide the following forms:

• UB-04 Claim Form — standard claim form for hospitals and other facilities
• CMS 1500 Claim Form — standard claim form for doctors and specialists

How to File Medicare Claims

Submitting Medicare claims

We have a contractual arrangement with the Centers for Medicare & Medicaid Services (CMS) to provide BSW SeniorCare Advantage HMO and BSW SeniorCare Advantage PPO Medicare Plans. The following applies to our SeniorCare (Cost) plans only.

Part A services

All claims billed on UB-04 for Part A services should be filed with Medicare Part A. We do accept crossover claims from Medicare. If you bill secondary claims to us for Medicare primary claims, we are now receiving daily electronic files from Medicare and will be processing provider payments from these electronic Medicare submissions.

Part B services

We act as the Medicare intermediary for some Part B services for SeniorCare members only. Please refer to your contract for further details.

Exceptions

CPT codes 90801-90899 for psychiatric services and 90918-90999 for dialysis should be filed directly with CMS.

Coordination of Benefits

Who pays first when there's duplicate coverage?

When your patient has more than one insurance provider, we follow Coordination of Benefits (COB) standards to determine if we're the primary or secondary payer. These are standards set by the National Association of Insurance Commissioners (NAIC).

We coordinate benefits payable for covered services with benefits payable by other plans, consistent with state law. Claims submitted to BSWHP for secondary payment must include the primary carrier's Explanation of Benefits (EOB).

Please note that if we're reimbursing services as a secondary carrier, our policies and procedures regarding referral, prior authorization and prior approval must still be followed.

If you have any COB questions or need clarification on how to coordinate benefits, give us a call.

Medicare coordination of benefits guidelines

Workers' Compensation (Third-Party Liability)

When a patient is injured on the job — whether in-office or off-site — we want to help get them back to work. All workers' compensation claims should be filed directly with us.

Subrogation

Sometimes, your patient's employer or a third party may be financially responsible for work-related medical services for an accident or injury that we've already covered. This is known as subrogation. In this case, we have the right to be reimbursed for these medical services.

If your office becomes aware of a possible subrogation claim, complete the accident form. Then contact The Bratton Firm via one of three ways:

• Call 800.741.4926
• Fax accident form to 512.477.6081
• Mail accident form to:
  The Bratton Firm
  1100B Guadalupe St.
  Austin TX, 78701

Your patients may also contact The Bratton Firm to learn more as well.

For additional information on any subrogation claim, contact Customer Advocacy at 800.321.7947.

Account Reconciliation

A mistake was made — let's reconcile

Even when claims are properly documented, there's always the chance of error. We work hard to identify and resolve accounting issues so correct payments can be made.

Retractions & recoupments

Retractions and recoupments are made for various reasons, including:

• Duplicate payment on a procedure
• Incorrect payment on a procedure
• Payment to the wrong provider

To make a retraction or a recoupment, you'll need to file an appeal.

Returned checks

If you return a BSWHP check for an adjustment, attach the following documents:

• An explanation for the adjustment
• A copy of the EOP
• Copies of prior payments
• Any other documentation explaining the payment discrepancy

Send returned or misdirected (sent to the wrong payee) checks to:

Baylor Scott & White Health Plan
Attn: Voids and Refunds - Claims
1206 W. Campus Drive
Temple, TX 76502

Refund checks

For all BSWHP member claims, providers should send refund checks to reimburse money owed to BSWHP to:

Baylor Scott & White Health Plan
Attn: Claims Department
P.O. Box 840523
Dallas, TX 75284-0523

Locum Tenens Billing

We'll cover you when someone else is covering for you

Maybe you're going on vacation. Perhaps a clinician is ill. As a network provider, you may have locum tenens physicians and clinicians temporarily working in your office from time to time.

In these cases, it will be your responsibility to:

• Contact us to let us know who the locum tenens physician is and how long they'll be providing services
• Provide oversight of the locum tenens physician as it relates to services that can be performed and authorization/pre-certification requirements
• Provide reimbursem*nt to the locum tenens physician

Services performed by the locum tenens physician should be billed to us under the provider name and number of the network physician who is providing oversight.

Statutory Verification

Senate Bill 418, enacted by the Texas Legislature, allows our contracted providers to verify payment of a claim for a member. Known as statutory verification, this serves as a guarantee of payment, if granted.

Declination

Declination is the refusal to give statutory verification. This does not equate with claim denial or adverse determination. It simply means we are unable to guarantee payment based upon the information we have at the time of the declination. We'll let you know the reason if we issue a declination.

Requirements

When requesting a statutory verification, you'll need to provide:

• Name of provider
• Provider's federal tax ID number
• Patient name
• Patient BSWHP ID number
• Patient date of birth
• Patient relationship with enrollee
• Presumptive diagnosis, if known; otherwise, presenting symptoms
• Description of proposed procedure or procedure codes
• Place of service code where services will be provided; if other than provider's office, name of hospital or facility where proposed service will be provided
• Proposed date of service
• Group number
• Name and contact of any other carrier, if known to provider

To request a statutory verification, contact us and provide the state-mandated required elements. For a routine care statutory verification, we will respond within five days.