Skip to Content

Information from your health plan about COVID-19 (coronavirus disease)

Learn more

Provider Manual

Sterilization: Hysterectomy Coverage

Last Updated on April 22, 2021

Security Health Plan follows ForwardHealth guidelines for coverage of hysterectomies. Security Health Plan does not require prior authorization or a second opinion when completed with an affiliated provider. The hysterectomy must be medically necessary and not solely for the purpose of rendering the patient sterile. Hysterectomies are not covered for uncomplicated fibroids, a fallen uterus or a retroverted uterus.

Reimbursement for hysterectomies is dependent on providers fulfilling all federal and state requirements and satisfactory completion of an Acknowledgement of Receipt of Hysterectomy Information form.

For a direct link to the Acknowledgement of Receipt of Hysterectomy Information form or for information on when the form is not required, see ForwardHealth Topic 581. See Physician’s Handbook https://www.forwardhealth.wi.gov/WIPortal/

  • Click on Online Handbooks
  • Choose the I Accept radio button and click Submit Agreement
  • Under Choose a user type, select Provider
  • Under Choose a program, select BadgerCare Plus and Medicaid
  • Under Choose a service area, select Physician
  • Under Sections and Chapters, select Covered and Noncovered Services
  • Choose Surgery Services
  • Select Hysterectomies

Consent form requirements

  1. The Acknowledgement of Receipt of Hysterectomy Information form must be completed prior to the procedure. This form may be photocopied.
  2. The Acknowledgement of Receipt of Hysterectomy Information form does not require a waiting period prior to the procedure.
  3. The completed form should accompany the claim and can be submitted via mail, email or fax:

    Security Health Plan
    Attn: Claims Department
    P.O. Box 8000
    Marshfield, WI 54449-8000

    Email: shpgovt.claimprocess@securityhealth.org

    Fax: Security Health Plan Claims Department at 715-221-9500

  4. Corrections to the forms are allowed, however providers should not white out any previously completed information. Instead, providers should strike through the incorrect information and add the corrected information. The provider must initial and date next to the corrections; if it is a member field then the member must initial and date next to the changes.