Provider Manual
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BadgerCare Plus
- Benefit Information
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Care Management
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Additional ProgramsChronic Care ManagementHealth Risk AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsTechnology AssessmentWellness and Health Promotion
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Claims Processing Policies and Procedures
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Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsNon-Covered ServicesOptical Eyewear Order GuidelinesOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Validation for Claims ProcessingProvider Remittance Advice StatementReimbursement Recovery ProcessReference outside Laboratory Billing ProtocolSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormWhen Security Health Plan is primary bill for any serviceWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- ForwardHealth
- HealthCheck
- Important Disclosures
- Member Information
- Product Overview
- Provider Directory
- Provider resources for Program Integrity Training
- Rights and Responsibilities
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Utilization Management
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Acute Rehab AdmissioneviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHospital admissions - pre-certificationHospital Observation AdmissionSterilization: Hysterectomy CoverageLong term acute care admissionMusculoskeletal proceduresNaviHealth/Skilled Nursing Facility CareNorthwoodPhysical, Speech and Occupational Therapy - OutpatientPre-certification Notification and Concurrent Review GuidePrior Authorization for Non-affiliated ProvidersPrior authorizationProvider Appeal and Grievance PolicySecond OpinionServices Related to Oral AppliancesSleep managementUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
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Family Health Center
- Benefit Information
- Care Management
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Claims Processing and Policies and Procedures
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Claims Coding ResourceClaims Payment CalendarCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference Outside Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Important Disclosures
- Member Information
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Pharmacy
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Claims ProcessingDrug FormularyFormulary ExceptionGeneral ExclusionsGeneric SubstitutionNetwork PharmaciesOffice/Medical Setting Administered Medications that require prior authorization Over-the-counter Medication CoveragePrior AuthorizationStep TherapyTobacco Cessation CoverageUtilization Management
- Program Overview
- Rights and Responsibilities
- Utilization Management
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Group & Direct Pay
- Benefit Information
- Care Management
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Claims Processing Policies and Procedures
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Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingOffice Infusion ProtocolOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- HCC - Risk Adjustement/Government Programs
- Important Disclosures
- Member Information
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Pharmacy
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Claims ProcessingDrug FormularyFormulary Exception Requests/Authorization RequestsGeneral ExclusionsGeneric SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Over-the-Counter MedicationPrior AuthorizationStep TherapyTablet Splitting Incentive OptionTobacco Cessation CoverageUtilization Management
- Product Overview
- Provider Directory
- Rights and Responsibilities
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Utilization Management
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Acute Rehab AdmissionDurable Medical Equipment and Home Respiratory EquipmenteviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome IV Drug TherapiesHospice ProtocolsHospital Admissions - Pre-certificationHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionMusculoskeletal proceduresNaviHealthNorthwoodOutpatient Therapy Treatment ConcurrentPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionSleep managementUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
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Medicare Advantage
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Benefit Information
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Benefit ExplanationContinuity and Coordination of CareCoverage Specifics for Certain ServicesCovered BenefitsDental BenefitsDepression in Primary Care GuidelinesEmergency and Urgently Needed Care CoverageHearing AidsHome INR MonitoringMacular Degeneration Eye InjectionsMental Health Medication ManagementPsychological TestingSecurity Health Plan Copayment StructureSkilled Nursing Facility
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Care Management
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Additional ProgramsAdvance Directive PolicyCoverage DeterminationEnd Stage Renal Disease (ESRD) Care CoordinationHealth Risk AssessmentHospice Care CoordinationNational Committee for Quality AssuranceNotice of Medicare NoncoverageOutpatient Observation Frequently Asked QuestionsPreventive Service GuidelinesPrograms for MembersQuality Improvement/Utilization Management Program OverviewSecurity Health Plan ProtocolsTechnology AssessmentTwo Midnight RuleWellness and Health PromotionOutpatient Observation Frequently Asked Questions
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Claims Processing Policies and Procedures
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Billing and ReportingClaims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- HCC - Risk Adjustement
- Important Disclosures
- Member Information
- Pharmacy
- Primary Care Provider
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Product Overview HMO and D-SNP
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Ally Rx D-SNP Model of CareDiscussion of Disenrollment from Medicare Advantage PlansEncounter Data PolicyMedicare Advantage Part D Data SubmissionsMedicare Advantage Part D Reporting RequirementsMedicare Advantage Reporting RequirementsRecipient of Federal Funds PolicyWhat are Medicare Advantage Plans?
- Provider Directory
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Rights and Responsibilities
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Access StandardsMedical policiesProhibition of Interference with Health Care Professionals Advice to Medicare Advantage MembersProvider ContractingProvider Credentialing ProcessProvider Reporting of Member ComplaintsProviders' Expectations of Security Health PlanSecurity Health Plan's Expectations of ProvidersSkilled Nursing Facility Denial of Medicare/Medicaid Payment
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Utilization Management
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Acute Rehab AdmissionAuthorization of Inpatient CareeviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome IV Drug TherapiesHospital Admissions - Pre-certificationHospital Inpatient Utilization ReviewHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionMusculoskeletal proceduresNaviHealthNorthwoodPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior Authorization for Nonaffiliated ProvidersPrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionSleep managementUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
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Benefit Information
When Security Health Plan is primary bill for any service
Providers should always bill Security Health Plan for a member’s complete inpatient length of stay or other services provided such as office visits, physical or occupational therapy to name a few. Security Health Plan prior authorizes inpatient stays that meet medical necessity and other criteria based upon member benefits. Sometimes a member’s Security Health Plan benefits do not cover the entire length of stay. A secondary payer or the patient may be responsible for these non-covered days or non-covered charges.
It is important to bill Security Health Plan for the entire stay or other services provided whether these are inpatient or outpatient charges. Security Health Plan will then generate an EOB to deny the non-covered days or other services with the appropriate ANSI code(s). Providers should then submit the EOB to the secondary payer (including Medicare and Medicaid) along with the claim for secondary coverage.
If Medicare or Medicaid do not receive EOBs including the denied days or other services, a CMS contractor generates a demand letter asking the primary insurer, an employer, or other plan sponsor to pay for these days or other services. These letters may be generated years after the date(s) of service at which time the primary payer then has to reprocess the claim(s), deny the non-covered days with the appropriate ANSI code(s), and submit detailed documentation to Medicare or Medicaid. This generates an EOB to the provider and to the member long after the claim was appropriately paid.
If providers initially submit completed claims to Security Health Plan for the entire length of stay or other services provided, Security Health Plan can avoid the extra work and confusion for providers, employer groups, and members.
Contact the Contract Manager if there are questions.