Here is your go-to guide for RightCare

Provider Manual

Filled with useful information, your Provider Manual helps you care for your patients in the way they need care.

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• Download RightCare Provider Manual (view or print)
• RightCare Provider Manual Table of Contents
• Important phone numbers
• Billing information
• Service that require prior authorization
• Referral information
• Provider Appeal Process to HHSC

Provider Information

RightCare Provider Relations and Services Hotline (including claims questions)

1-855-TX-RIGHT (1-855-897-4448)

Provider Representatives

View Provider Representatives Territory Map.

Contracting

Become a Network Provider

Thanks for your interest in becoming a contracted provider. We're always looking for exceptional providers to join our growing network of physicians and hospitals. Together, we can help you give your patients—and our members—the quality, cost-efficient care they deserve. Start the application process today.

See below for links to information about applying to SWHP and Aperture—our Credentialing Verification Organization (CVO).

Helpful Links:

• Process for joining SWHP
• SWHP FAQ on new Aperture CVO

Healthcare Providers

Apply to join our provider network.

• New Facility Contract Form
• New Individual & Group Contract Form

Credentialing

Provider Newsletters

Read the Provider Newsletter for trending articles and Medicaid product and benefit information.

Provider Advisory Group

RightCare 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, SWHP Provider Services, Medicaid Operations staff, and the RightCare Medicaid Medical Director. SWHP will review phone calls and complaint logs to determine patterns of concern that need to be addressed. SWHP 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 RightCare website. RightCare will utilize technology to engage providers across the service area. For more information on Provider Advisory Groups, please contact RightCare Provider Relations at 1-855-TX-RIGHT (1-855-897-4448).

Provider Notices and Reminders

Looking for the latest Provider News, click here.

Texas Medicaid Formulary

Preferred Drug List

Texas Health Steps Online Training

TMHP Provider Enrollment

Cultural Competency

It is critical that RightCare providers develop a culturally competent system of care — one that acknowledges and incorporates at all levels the importance of culture and the adaptation of services to meet culturally-unique needs.

RightCare members vary in language and culture (e.g., customs, religion, backgrounds, etc.). Our goal is to effectively serve members of all cultures, races, ethnic backgrounds and religions in a manner that recognizes values, affirms and respects the worth of the individuals and protects and preserves the dignity of each. We must operate at a level in which cultural knowledge is high and policies and practices are in place that produces positive results and satisfaction from the viewpoint of the culturally diverse client.

Provider Complaints

Filing Complaints to RightCare

If a provider is dissatisfied with RightCare’s policies, procedures, coverage or benefit decisions or with any aspect of the member’s treatment by physicians, hospitals or other providers, he or she have the legal right to file a complaint to RightCare and/or the Health and Human Services Commission (HHSC).

Provider can file a verbal complaint by calling Customer service at 1-855-897-4448/ TTY 771. RightCare recommends that all complaints received from providers be submitted in writing to:

• RightCare from Scott & White Health Plan
  Attn: Dispute Resolution MS-A4-144
  1206 W. Campus Drive Temple, TX 76502
• Or by email to: swhpappealsandgrievances@bswhealth.org
• or fax to 1-254-298-3086.

Note: Any complaints received at the wrong address will be returned to the sender.

Provider Complaint Process to HHSC

A provider who believes that they did not receive full due process from RightCare may file a complaint with HHSC. Providers must exhaust the complaint process with RightCare before filing a complaint with HHSC. Complaints can be submitted orally or in writing and received by HHSC at the following address:

• Texas Health and Human Services Commission
  Medicaid/CHIP
  Health Plan Management
  Mail Code H-320
  P.O. Box 85200
  4900 N. Lamar Blvd.
  Austin, TX 78708-5200
• Or by e-mail to: HPM_Complaints@hhsc.state.tx.us or
• Fill out this online form: txhhs.my.site.com/complaint/s/

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. RightCare will adjudicate all appeals within 30 days of receipt of the appeal.

Submit all correspondence to:

• Scott and White Health Plan
  P.O. BOX 211342
  Eagan, MN 55121-1342
• Electronic submission through provider portal: rightcare.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 1-855-897-4448; email claimappealsprovider@BSWHealth.org; fax 1-254-298-3086

24/7 Virtual Care - With MyBSWHealth, you can get care anytime—no matter where you are in Texas. All you need is Wi-Fi or a cell signal and a phone, computer or tablet. Want to know more? See our step-by-step guide.