Scott & White Health Plan

Customer Service

SWHP is dedicated to serving you and your family. To enhance our service to you, Customer Service Advocates are available through telephone, e-mail, personal meetings or by appointment. Customer Service Advocates can assist you in many ways. They help you take full advantage of your SWHP benefits by:

• Answering questions about using SWHP
• Explaining your benefits
• Helping you choose or change your PCP
• Assisting you in resolving complaints and appeals
• Sending you printed materials upon your request

To contact a Customer Service Advocate, call or e-mail a SWHP office near you.

Language Line

In an effort to improve communication with non-English speaking enrollees, SWHP uses the interpretive services of AT&T. When calling a SWHP representative, you will be linked to a highly trained interpreter. Simply let a Customer Service Advocate know your primary language and the call will be completed with the help of an AT&T interpreter. You do not have to call a special line for this service.

Information about Practitioners

If you would like to know the professional qualifications of a SWHP network PCP or practitioner, contact a Customer Service Advocate at a SWHP office near you. You can inquire about your physician's medical school, residency completion, board certification status and any other information you may need to choose a practitioner in the network. Or visit Find a Provider to find a physician in your area, his/her gender, languages spoken and board certification.

Complaints and Appeals

SWHP is dedicated to addressing your grievances and resolving them promptly. If there is ever a time when you are not satisfied with the performance of SWHP or one of its providers, you should contact a Customer Service Advocate immediately. All grievances are documented and thoroughly investigated. SWHP encourages your input and will not discriminate against you, refuse coverage, or engage in any other retaliation if you choose to file a complaint or request an appeal of a decision. Additionally, SWHP is prohibited from retaliating against a physician or provider who has filed a complaint against SWHP on your behalf.

SWHP's definition of a complaint is an oral or written form of dissatisfaction that is not able to be resolved promptly to your satisfaction. When you call a Customer Service Advocate to express dissatisfaction, he/she will immediately document your issues and send you a complaint form (as required by the Texas Department of Insurance) to complete and send back to SWHP. This form does not go into your medical record; it simply helps SWHP address your complaint with the appropriate person or department. SWHP responds to the oral and written complaints in the same manner and informs you of a resolution within 30 calendar days of receipt of the complaint.

SWHP's definition of an appeal is a request for SWHP to reverse a previous adverse decision. All appeals are presented to a panel, which is held within 30 calendar days after receipt of the request. You have the right to appear before the panel and to present written or oral information in support of your request to reverse the previous decision. The SWHP will permit and pay for an immediate appeal to an independent review organization in the event the decision rendered was an Adverse Determination (denial of coverage based on medical necessity determination) to the complainant and the request was presented to the SWHP within 180 days of the previous decision. For more information on your appeal rights, please contact a Customer Service Advocate at a SWHP office near you.

Identification (ID) Card

As a SWHP enrollee, you will receive an identification card. You should carry your card with you at all times and present it to the desk personnel when reporting for appointments. The identification card identifies you and each member covered as a SWHP enrollee, includes your ID number and your required co-payment for different services. Instructions for out-of-network care are located on the back of the card. Be sure all information on the card is accurate. If there are any errors or omissions, please call a Customer Service Advocate at a SWHP office near you. If you need to order additional cards, you may do so by selecting Request an ID Card or by contacting a Customer Service Advocate at a SWHP office near you.

Maternal Options Maintenance Support (MOMS)

Sometimes new mothers feel a little overwhelmed. MOMS is an optional program that provides valuable family support following your baby's birth. Through personal phone calls, our knowledgeable licensed nurses answer routine questions about mom and baby care, provide tips for healthy lifestyle habits and help mothers and their families get off to a great start. For more information on MOMS, visit the Maternal Options Maintenance Support page.

Requests for Coverage of New Technical Procedures

SWHP has a process whereby a group of physicians and other health care professionals evaluate requests for coverage of new technological procedures or treatments. The Technical Assessment Committee receives from a requesting doctor a proposal to SWHP that outlines a new or currently uncovered medical or behavioral procedure, device or treatment; the perceived advantages over current therapy; criteria for utilization; and supporting papers from peer-reviewed scientific journals.

The Technical Assessment Committee then meets to evaluate the physician's request for coverage. The recommendations of the Technical Assessment Committee are presented to the SWHP Quality Improvement Committee for a final approval determination. If you have a request of coverage for a new medical or behavioral procedure, device or treatment, please contact your physician or the Health Services Division at (888) 316-7947.