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Provider Manual

Provider appeal and grievance policy

Last Updated on October 25, 2021

All provider appeals must be submitted using Security Health Plan’s Formal Provider Appeal form located below. The form must be complete and provide an explanation of why the services should be reviewed. Any supporting documentation should be included at the time of the appeal. Security Health Plan's appeal decision is based on the materials available at the time of formal appeal review. Any appeal that is received without this form, or with an incomplete form, will not be processed as a formal provider appeal.

Formal Provider Appeal form

Appeal related to post-service claim payments/denials 

Providers have the ability to resubmit a claim (within timely filing guidelines), request reconsideration and/or appeal claim payments/denials.

  • Resubmit a claim: submit a new claim with changed or added information that may result in a different claim determination. Click here for more information on resubmitting a corrected claim.
  • Request reconsideration of a claim: an informal verbal or written request for Security Health Plan to review a claim that the provider feels was incorrectly processed 
  • Appeal: a formal request for review of a claim determination when the provider does not agree with the claim reconsideration decision

Requesting reconsideration (requests for information regarding a claim payment/denial for services) 

  • Security Health Plan will accept telephone or written requests
  • The request will be directed to the claim examiner 
  • The claim examiner will answer the provider’s questions, investigate information, and attempt to resolve the issue with the provider 
  • If the provider disagrees with the response given to the claim reconsideration, the provider may appeal by following the 'Requesting an appeal' section below.
  • If the provider identifies they have an error on the claim they may submit a corrected claim if within the timely filing window. Click here for more information on resubmitting a corrected claim.
  • While a reconsideration request can be submitted at any time Security Health Plan recommends they be done within appeal and claim resubmission timeframes to avoid missing these deadlines.

Requesting an appeal

No post-service appeals may be submitted until the claim has been received and denied in full or in part. If a finalized claim has not been received the appeal will be returned to the provider.

Commercial, Medicare Advantage, FHC, Medicare Supplement products: Appeals must be submitted within 365 calendar days from the provider’s statement on which the charge was denied or reduced.

Medicaid Managed Care Programs: Appeals must be submitted within 60 calendar days from the provider’s statement on which the charge was denied or reduced.

  • Complete Security Health Plan’s Formal Provider Appeal form. If this form is not used, it will not be considered a formal appeal. Include all relevant information to support why the original denial should be overturned.
  • If you are a non-contracted provider appealing a post-service denial for our Medicare Advantage, Ally-Rx D-SNP or Secure Saver MSA plans, complete the Waiver of Liability form as required by section 50.1.1 of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.
  • Gather all documentation supporting why the claim is being appealed. Security Health Plan will not make any attempts to gather additional information/documentation from providers. Failure to submit complete documentation may lead to upholding of the original denial.
  • Completed appeals should be submitted via:

    Fax: 715-221-9650
    Email: shp.claims.provider.appeals@securityhealth.org
    Mail: Security Health Plan
    Attn: Claims Department Appeals
    P.O. Box 8000
    Marshfield, WI 54449-8000

  • Appeals will be reviewed by Security Health Plan's Provider Appeals Committee.
  • Security Health Plan will respond in writing within 45 calendar days from the receipt of a complete appeal. For Medicaid Managed Care Programs appeals, Security Health Plan will respond within 45 days from the date on the Formal Provider Appeal form. An appeal is considered a complete appeal when all requested information from Security Health Plan is received.
  • Security Health Plan’s response to the provider on appeals is final and will be in writing.

Medicaid Managed Care Programs appeals only

  • View the HMO and PIHP Member Grievances and Appeals Guide
  • Providers are required to use Security Health Plan’s appeals process prior to initiating an appeal with the State.
  • Providers have the right to appeal to BadgerCare Plus and Medicaid SSI, Managed Care Unit – Provider Appeal if Security Health Plan fails to respond to the appeal within 45 days of receiving the appeal or if the provider is not satisfied with Security Health Plan’s response to the appeal (also called a “request for reconsideration”). All appeals to BadgerCare Plus and Medicaid SSI, Managed Care Unit – Provider Appeal must be submitted in writing within 60 days of Security Health Plan’s final decision. Submit completed appeals using form F12022 (07/17) Managed Care Provider Appeal Form to:

    BadgerCare Plus and Medicaid SSI Managed Care Unit — Provider Appeal
    P.O. Box 6470
    Madison, WI 53716-0470
    Fax: 608-224-6318
  • Visit ForwardHealth’s Topic 385 Appeals to ForwardHealth for further information on submitting an appeal to BadgerCare Plus and Medicaid SSI, Managed Care Unit – Provider Appeal.

Non-contracted provider appeals for Medicare plans only

If Security Health Plan renders a partial or fully adverse decision, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare's Independent Review Entity (IRE). They will review the appeal within 60 calendar days to make sure the correct decision was made. You will receive correspondence by mail regarding their decision.

If the IRE renders a favorable decision for you, Security Health Plan must effectuate and comply with the IRE's decision. A new Remittance Advice will be sent to reflect the IRE's decision.

Appeals related to pre-service or medical necessity denials

Provider appeals related to adverse determination based on medical necessity

Security Health Plan denies coverage of a service or supply that is determined not medically necessary, not appropriate, or excluded because it is considered to be experimental or investigational. Security Health Plan uses nationally recognized criteria when making coverage determinations. A provider may appeal adverse determinations for prior authorization, pre-certification, referral authorization, or hospital stays in part or in total. When appealing an adverse determination, the request for a reconsideration of the adverse determination must be supported with additional information or written documentation from the medical record that was not previously reviewed by the Security Health Plan medical director. The medical director will at his/her discretion consult with like-specialty physicians.

Process for appeals

  • Appeals must be submitted and received within 60 calendar days from the date of the adverse determination and notification to provider of this determination. 
  • Appeals must be complete and contain all pertinent information.  An appeal decision will be based only on the information submitted by the provider.
  • Appeals related to:
    • a prospective review may be conducted via telephone with a medical director by calling 715-221-9659, option 1, or filing a written appeal when the requested service has not occurred. 
    • a concurrent review should be directed per the expedited appeal policy. The provider may call the Health Services Department at 715-221-9659 and request an expedited appeal for concurrent review cases only. The member must currently be an inpatient. A decision will be made as expeditiously as the medical condition requires, but no later than 72 hours after the review commences. 
    • a retrospective review must be filed as a formal written appeal. 
  • Formal appeals must be submitted in writing  with formal appeal form within 60 days of the adverse determination, when the requested service has been provided. If appeals are received without use of this form or if the form is incomplete they will not be processed as a formal provider appeal.
  • Submit pre-service or medical necessity denial appeals by:

    Email: shp.claims.provider.appeals@securityhealth.org
    Mail: Security Health Plan
    Attn: Claims Department Appeals
    P.O. Box 8000
    Marshfield, WI 54449-8000

  • Formal appeals will be reviewed by the Security Health Plan Medical Provider Appeals Committee.
  • Security Health Plan will respond in writing within 45 calendar days from the receipt of a complete appeal. For Medicaid Managed Care Program appeals, Security Health Plan will respond within 45 days from the date on the provider appeal form. An appeal is considered a complete appeal when all requested information from Security Health Plan is received. 
  • Security Health Plan’s response to the provider on appeals is final and will be in writing.

Availability of medical directors

  • To ensure fair and consistent decision-making, providers have the opportunity to discuss with a Security Health Plan medical director denials that are based on medical necessity or considered to be experimental or investigational. If the requesting or primary physician would like to discuss a case with a Security Health Plan medical director, call 715-221-9659.