CurrentBaylor Scott & White Health PlanPolicy N/A

ASO Claims Payment Policy

Governs claims submission, processing, payment timelines, redetermination requests, and recoupment/refund procedures for Self‑Funded (ASO) employer health plans administered by Scott & White Health Plan and affecting participating providers/facilities.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyASO Claims Payment Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 21, 2016

Next Review DateN/A

Key ActionProviders may submit a one-time redetermination request using the Provider Claims Redetermination Request Form within 90 days of the original determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yeartimely filing window for providers to submit claims

30 dayselectronic claim processing time

45 daysnon-electronic claim processing time

90 dayswindow to request redetermination

30 daysredetermination processing time

180 daysplan overpayment refund request window

Claims submission, payment, redetermination, and recoupment timelines

Operational claims and recoupment criteria

Operational criteria and timelines governing claim submission, processing, redetermination, and recoupment:

Providers have 1 year from the date of service to submit a claim; claims submitted after 1 year will be denied for nontimely filing.

Processing and payment timelines

Non‑contract providers
- Electronically submitted claims must be processed and paid within 30 days from receipt.
- Non‑electronically submitted claims must be processed and paid within 45 days from receipt.
Contract providers

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyASO Claims Payment Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 21, 2016

Next Review DateN/A

Key ActionProviders may submit a one-time redetermination request using the Provider Claims Redetermination Request Form within 90 days of the original determination.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Unless otherwise stated in an executed provider contract, electronically submitted claims must be processed and paid within 30 days from receipt.

Unless otherwise stated in an executed provider contract, non‑electronically submitted claims must be processed and paid within 45 days from receipt.

Claims will be processed and paid in accordance with the member's Benefit Schedule as outlined in the SPD; ASO employer (client) may authorize exceptions in writing.

Redetermination submission

Providers may submit a single one‑time redetermination request for a previously processed claim using the Provider Claims Redetermination Request Form; failure to complete the form will result in the request being returned for completion.
Redetermination requests must be submitted within 90 days from the original determination date.
Multiple redetermination requests submitted on the same claim will not be processed and will be returned as 'previously reviewed'.

Redetermination timing and payment

Redeterminations will be processed within 30 days from date of receipt.
Payment (if applicable) will be made within 15 days of the decision (i.e., up to 45 days from receipt of the redetermination request).

Recoupment and refunds

The plan will request refunds of overpayments in writing within 180 days from the payment date.
Providers have 45 days from the date of receipt of the refund request to dispute or make arrangements to refund the overpayment to the Health Plan.
If no action is taken within the 45‑day period, recoupment actions will be taken.
The BSW contract requires that a written request for overpayment be presented and prohibits offsetting member accounts.

Submission of a corrected claim is treated as a request from the provider/facility to reprocess the claim and may result in recoupment actions for overpayments; no separate refund request will be sent for corrected claims.

How providers request redetermination and required forms

Prior Authorization

One-time provider redetermination using required form and timing

Providers may submit a single one-time redetermination request for a previously processed claim by completing and submitting the Provider Claims Redetermination Request Form. Requests must be submitted within 90 days of the original determination; multiple requests on the same claim will be returned as “previously reviewed.” Redeterminations are processed within 30 days of receipt and, if payment is due, payment will be made within 15 days of the decision (45 days from receipt of the request).

Complete the Provider Claims Redetermination Request Form — incomplete forms will be returned.
Submit the request within 90 days of the original determination date.
Do not submit multiple redetermination requests for the same claim (will be returned as previously reviewed).
Expect processing within 30 days of receipt and payment within 15 days of decision (45 days from receipt).

Key definitions used in this policy

Redetermination

DefinitionRedetermination: The review of a previously adjudicated processed claim at the request of a provider to assess if the original determination/decision was correct or should be reversed based on additional information not previously available during the original determination.

RequesterInitiated by the provider or facility who originally submitted the claim.

PurposeTo assess whether the original adjudication should be reversed based on new or previously unavailable information.

Recoupment

DefinitionRecoupment: The recovery of previously paid expenses for a legitimate reason through a written request to the provider or facility OR a reduction or withholding of part or all of an owed amount to a provider or facility.

MethodRecovered via written request to the provider/facility or by reducing/withholding amounts owed.

ReasonUsed when an overpayment or other legitimate basis for recovery is identified.

ASO Plan

DefinitionAdministrative Services Only (ASO) Plan: An ASO plan is a self-funded Employer Health Insurance Plan where the employer is exclusively liable for all the financial (claim and related expenses) and legal aspects of the group benefit plan; SWHP is paid a fee to administer the ASO Health Plan.

Financial LiabilityEmployer bears exclusive financial responsibility for claims and related expenses under the ASO arrangement.

AdministrationThe plan administrator (SWHP) is paid a fee to administer the ASO health plan; ERISA guidelines govern operation and administration.