Out-of-network liability and balance billing

How to receive services from non-network health care providers

Unless your health plan, as specified in your Schedule of Benefits, provides access to non-network providers, services provided by non-network health care providers generally are not covered by Security Health Plan. However, benefits may be payable for services by a non-network health care provider if Security Health Plan determines that the service is not available from any network health care provider or as stated in your Schedule of Benefits.

For a service that requires prior authorization, have your health care provider contact Security Health Plan before the service is provided. With the exception of emergency or urgent care services, Security Health Plan will not pay for a service that has already been provided by a non-network health care provider, unless otherwise stated in a member’s Schedule of Benefits. All of the following criteria for prior authorization must be met:

  • The services are not available from any network health care provider
  • The services are a covered benefit under the member’s coverage
  • The services are medically necessary and appropriate

When a member receives prior authorization for a service from a non-network health care provider, the prior authorization will state the type or extent of evaluation and/or treatment authorized, the number of authorized visits, the period during which the prior authorization is valid, and the location for services. Any additional services recommended by and received from a non-network health care provider are not covered unless prior authorization is given.

Except for urgent and emergent care, reimbursement is limited for non-network benefits to the Usual, Customary, and Reasonable charges for cost-effective services, subject to applicable deductible, coinsurance and copayment amounts. If a charge exceeds our Usual, Customary, and Reasonable fee schedule, Security Health Plan may reimburse less than the billed charge and the member is responsible for any amount charged in excess of such fees, as well as applicable deductible, coinsurance and copayment amounts.

Remember: A recommendation or referral by a network health care provider to receive services from a non-network health care provider is not covered unless prior authorized by Security Health Plan or otherwise stated in a member’s Schedule of Benefits. Please have your health care provider contact Security Health Plan before you receive non-emergency or non-urgent services from non-network health care   providers.

Enrollee claims submission

Claims Processing Procedure

Types of claims

There are four categories of claims that can be made under this plan. The primary difference between these categories is the timeframe for determination and appeal. It is very important to follow the requirements that apply to your type of claim.

If you have questions about these Claims Processing Procedures or what type of claim you have, contact Security Health Plan at 1-800-472-2363.

The four categories of claims are:

    • Pre-service claim: A claim is a pre-service claim if the Certificate requires approval of the benefit in advance of obtaining the medical care, unless the claim involves urgent care, as defined below. Benefits under the plan that require approval in advance are specifically noted in this Certificate as requiring prior authorization. For benefits that do not require prior authorization, no advance approval is necessary, and any request for advance approval will not be treated as a claim.

    • Urgent care claim: An urgent care claim is a special type of pre-service claim. A claim involving urgent care is any pre-service claim for medical care or treatment with respect to which the application of the time periods that otherwise apply to pre-service claims could seriously jeopardize the claimant’s life or health or ability to regain maximum function, or would—in the opinion of a physician with knowledge of the claimant’s medical condition—subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. On receipt of a pre-service claim, Security Health Plan will make a determination as to whether it involves urgent care; in any event, a claim will be treated as an urgent care claim if a physician with knowledge of the claimant’s medical condition indicates that the claim involves urgent care.

    • Post-service claim: A post-service claim is any claim for a benefit under the plan that is not a pre-service claim, an urgent care claim, or a concurrent care claim.

    • Concurrent care claim: A concurrent care decision occurs where the plan approves an ongoing course of treatment to be provided over a period of time or for a specified number of treatments. There are two types of concurrent care claims:(a) where reconsideration of previously approved care results in a reduction or termination of the initially approved period of time or number of treatments; and (b) where an extension is requested beyond the initially approved period of time or number of treatments.

The claim type is determined initially when the claim is filed. However, if the nature of the claim changes as it proceeds through the claims process, the claim may be re-characterized. For example, a claim may initially be an urgent care claim. If the urgency subsides, then it may be re-characterized as a pre-service claim.

Filing a claim

In most cases, the health care provider submits claims directly to Security Health Plan. However, a member may also submit a claim.

Claims should be submitted to:
Security Health Plan
1515 North Saint Joseph Ave.
PO Box 8000
Marshfield, WI 54449

In light of the expedited time frames for urgent care claims, an urgent care claim for benefits may be faxed to 715-221-6616.

Claims should include at least the following information:
    • The identity of the claimant
    • The date(s) of service
    • The specific medical condition or symptom diagnosed; and
    • The specific treatment, service or product for which approval or payment is requested

Claims should be accompanied by proof of the claim.

Proof of claim: The member, or the health care provider on the member’s behalf, must submit written proof of the claim for each service to Security Health Plan within 90 days of the date on which the member received the service. Written proof of the member claim includes:

  • The completed claim forms if required by Security Health Plan
  • The actual itemized bill for each service
  • All other information that Security Health Plan needs to determine our liability to pay benefits under the coverage including, but not limited to, medical records and reports 

A claim will be treated as received by Security Health Plan (a) on the date it is hand-delivered to Security Health Plan at the indicated address; or (b) on the date that it is received by the health plan. Claims must be submitted by the applicable deadlines for the type of claim as indicated in these procedures. Unless otherwise indicated, when used in these claims procedures, the term “day” means a calendar day.

Proof of Claims

In most cases, the health care provider submits the claims directly to Security Health Plan. The member, or the health care provider on the member’s behalf, must submit to Security

Health Plan written proof of the claim for each service within 90 days of the date on which the member received that service. Written proof of the member claim includes:

  • The completed claim forms if required by Security Health Plan
  • The actual itemized bill for each service
  • All other information that Security Health Plan needs to determine our liability to pay benefits under the coverage including, but not limited to, medical records and reports In accordance with Wisconsin law, if circumstances beyond the member’s control prevent the member from submitting such proof to Security Health Plan within this time period, Security Health Plan will accept a proof of claim, if provided as soon as possible and within one year after the 90-day period. If Security Health Plan does not receive the written proof of claim required by Security Health Plan within that one-year-and-90-day period, no benefits are payable for that service.

Grace periods and claims pending policies during the grace period

When coverage ends

Security Health Plan can terminate coverage for members who do not pay their premiums.  Members who receive tax credits through the Marketplace have a three month grace period to allow you catch up with any late payments.  Members who do not receive tax credits through the Marketplace have a 10-day grace period in which to make a payment.  Payments are needed for any past due amount as well as other premiums that have come due during the grace period to prevent disenrollment.  Please be aware that disenrollment will not only affect the subscriber, but all enrollees who receive coverage through your policy.  Claims are not pended during the three month grace period. 

If Security Health Plan does not receive a member’s payment, the member’s coverage will end as of the month following the last date of paid coverage. 

The consequences of losing coverage include:

  • Repayment of any premium tax credits provided for months of coverage that are retroactively terminated. 
  • Inability to participate in special enrollment periods for the remainder of the benefit year, and
  • Individual responsibility for paying any medical claims incurred during the period of the retroactively terminated coverage.

If a member fails to pay his/her premium, the next month they will receive a past due Premium Statement advising that they have entered their first month of grace. The past due Premium Statement will be accompanied by a letter that advises the member of the grace period and consequences of losing coverage, including responsibility for paying any medical claims incurred during the period of retroactively terminated coverage.

Security Health Plan Enrollment staff will review the list of member terminations at the beginning of every month for special situations or unapplied funds. If unapplied funds greater or equal to the account balance are verified, or if payment in full is received, the policy is not terminated. If the member fails to pay in full by the end of his/her 90 day grace period, enrollment will be retroactively terminated at the end of the first month of grace. Month 2 and 3 of the grace period will no longer have active coverage.  The member then assumes responsibility for paying any medical claims incurred during the period of retroactively terminated coverage.

Retroactive denials

Security Health Plan retains the right to recover excess claim payments made in certain situations, including payment for services already received from your provider. Familiarize yourself with services covered by your plan, and any rules you must follow regarding those covered services. Always contact Security Health Plan before you receive any medical care, to verify coverage and avoid unforeseen bills.

  • If you fail to pay your health insurance premium, it may result in retroactive termination of coverage. If Security Health Plan has paid your claims beyond the date your plan was retroactively terminated, you will be responsible for the amount paid on those claims.
  • Claims are reviewed both before and after payment. If misleading, incomplete, fraudulent or excluded services have been paid, Security Health Plan may retroactively adjust our claim payment, and you could be held responsible for that amount.
  • If Security Health Plan paid for medical services which are subsequently found to be work-related, you may be responsible for the amount paid by Security Health Plan.

Enrollee recoupment of overpayments

When a subscriber has overpaid their premiums, there will be a credit of the overpayment amount on their account.  Credits greater than two months’ worth of premium, may be returned in the form of a check upon request. Overpayments are not automatically refunded on active accounts. 

All refund requests must be made by the subscriber and will be mailed to the subscriber’s address on file.  Refund checks may take up to 60 days for the subscriber to receive from the date of the request due to processing and mailing times.

Medical necessity and prior authorization timeframes and enrollee responsibilities

Prior authorization and shared decision-making

There are certain medical services for which you are required to contact Security Health Plan before you receive the service or care. These may include services, such as pain management, spinal surgery, new technologies (may be considered experimental/ investigational/ unproven), non-emergency ambulance, high-cost durable medical equipment, certain high-technology imaging, or procedures that could potentially be considered cosmetic.

You can find a current list of health care services for which prior authorization is required in your Schedule of Benefits. You can also visit our website at www.securityhealth.org/authorization or call our Customer Service Department at 1-800-472-2363 to find out what services require prior authorization.

How to Request a Prior Authorization

Your health care provider can start the prior authorization process by calling our Provider Assistance Line at 800-548-1224 or by downloading a printable prior authorization form from our website at www.securityhealth.org/priorauthorization. After the health care provider submits a prior authorization request, we suggest that you check My Security Health Plan, online at www.securityhealth.org to verify the status. Except in the case of an prior authorization request that is deemed urgent, please allow up to 14 business days for the review process. Although your health care provider should initiate the prior authorization process, it is your responsibility to ensure that: 

a. the prior authorization request form is obtained and completed in consultation with your health care provider
b. the prior authorization request is submitted to and received by us
c. the prior authorization request is approved by us before you obtain the applicable health care services

After we review your request, we will send a written response to you and/or the health care provider who submitted the request. Our benefit determination(s) will be based upon the information available to us at the time we receive your request.

If we approve your request, our prior authorization will only be valid for:

a. the covered person for whom the prior authorization was made;
b. the health care services specified in the prior authorization and approved by us; and
c. the specific period of time and service location approved by us as specified in the approval letter.

Consequences for Failing to Obtain a Prior Authorization

Failure to comply with the prior authorization process outlined in this subsection will result in no benefits being paid under the policy. Please refer to your Schedule of Benefits for a list of prior authorizations.

Drug exceptions timeframes and enrollee responsibilities

  • Security Health Plan reserves the right to limit coverage of daily dosing regimens to FDA-approved dosing as defined by the manufacturer and clinical best-practice guidelines The Formulary is reviewed and updated every month. Most changes involve adding new drugs or drugs that are newly available in generic form. At times, drugs are removed from the formulary or moved to restricted status. Members and providers are encouraged to review the Security Health Plan website at www.securityhealth.org/prescriptiontools on a regular basis for the most recent updates
  • For prescriptions not submitted electronically, any amounts in excess of the contracted charge for that drug
  • Supplies of prescription drugs exceeding $2,500 require approval from Security Health Plan before being dispensed. In such cases, Security Health Plan may limit quantities dispensed to a one-month supply or less as applicable to the medication and the intended course of treatment
  • When an exception is requested by the health care provider for non-formulary medications, the request should include: member name; health care provider’s name, address and telephone number; medication strength, dosage form and directions; diagnosis; lab medical data; and the medical reason for the request. Written requests should be sent to:

              Security Health Plan
              ATTN: Pharmacy Services
              PO Box 8000
              Marshfield, WI 54449-8000
              Or email us at:
              shprx@securityhealth.org
              Pharmacy Services can be reached at 1-877-873-5611

Medical exceptions

A member may request a medical exception (also called a formulary exception) for a non-formulary prescription drug or medical supply.  (For closed plans, an exception is also required for tier 3 drugs). The exception request may be initiated by the member, or by a provider acting on behalf of the member, in writing or by verbal request.

Standard coverage decisions for medical exceptions will be made no more than 72 hours following the receipt of the standard exception request.

Expedited coverage decisions for medical exceptions will be made no more than 24 hours following the receipt of the standard exception request.

Information on Explanations of Benefits (EOBs)

Coordination of benefits (COB)

When members have more than one plan

Applicability

This section applies to this plan when a member or a member’s covered dependent has health care coverage under more than one plan. “Plan” and “this plan”.

Plan: Any of the following that provides benefits or services for medical or dental care or treatment:

  • Group insurance or group-type coverage, whether insured or self-funded, that includes continuous coverage. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident-type coverage.
  • Coverage under a governmental plan or coverage that is required or provided by law. This does not include Medicare or Medicaid. It also does not include any plan whose benefits, by law, are excess to those of any private insurance program or other non-governmental program.
  • Medical expense benefits coverage in group, group-type and individual automobile “no fault” contracts but, as to the traditional automobile “fault” contracts, only the medical benefits written on a group or group-type basis are included.

This plan: the part of the policy that provides benefits for health care expenses. 

The order of benefit determination rules below govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100 percent of the total allowable expense.

Order of benefit determination rules

General – When there is a basis for a claim under this plan and another plan, this plan is a secondary plan that has its benefits determined after those of the other plan, unless those rules and this plan’s rules described below require that this plan’s benefits be determined before those of the other plan.

Rules – This plan determines its order of benefits using the first of the following rules which applies:

  • Other Plan with no rules – If the other Plan does not have rules coordinating its benefits with those of this Plan, the benefits of the other Plan are determined first.
  • Non-dependent/dependent – The benefits of the plan that covers the person as an employee, member or subscriber are determined before those of the plan that cover the person as a dependent of an employee, member or subscriber
  • Dependent child/parents not separated or divorced – except as stated below, when this plan and another plan cover the same child as a dependent of different people, called “parents:” A parent can be any individual who serves as a policyholder including, but not limited to, legal guardians, step-parents and parents
  • The benefits of the plan of the parent whose birthday falls earlier in the calendar year (month and day only) are determined before those of the plan of the parent whose birthday falls later in that calendar year; but
  • If both parents have the same birthday, the benefits of the plan that covered the parent longer are determined before those of the plan that covered the other parent for a shorter period of time

However, if the other plan does not have the rules described above but instead has a rule based upon the gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan shall determine the order of benefits.

  • Dependent child/separated or divorced parents – If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:
  • First, the plan of the parent with custody of the child
  • Then, the plan of the spouse of the parent with custody of the child
  • Finally, the plan of the parent not having custody of the child

However, if the specific terms of a court decree state that the parents have joint custody and do not specify that one parent has responsibility for the child’s health care expenses or if the court decree states that both parents shall be responsible for the health care needs of the child but gives physical custody of the child to one parent, and the entities obligated to pay or provide the benefits of the respective parents’ plans have actual knowledge of those terms, benefits for the dependent child shall be determined according to rules found in the dependent child/parents not separated or divorced section.

Also, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. This paragraph does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.

  • Active/inactive employee – The benefits of a plan that covers a person as actively employed are determined before those of a plan that covers that person as a laid-off or retired employee or as that employee’s dependent. If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule is ignored. If a dependent is a Medicare beneficiary and if, under the Social Security Act of 1965 as amended, Medicare is secondary to the plan covering the person as a dependent of an active employee, the federal Medicare regulation will supersede this paragraph
  • Continuation coverage – If a person has continuation coverage under federal or state law and is also covered under another plan, the following shall determine the order of benefits:
  • First, the benefits of a plan covering the person as an employee, member or subscriber or as a dependent of an employee, member or subscriber
  • Second, the benefits under the continuation coverage
  • Longer/shorter length of coverage – If none of the above rules determines the order of benefits, the benefits of the plan that covered an employee, member or subscriber longer are determined before those of the plan which covered that person for the shorter time

Effect on the benefits of this plan

  • When this subsection applies:

This subsection applies when, in accordance with “Order of Benefit Determination Rules,” this plan is a secondary plan as to one or more other plans. In that event, the benefits of this plan may be reduced under this subsection. Such other plan or plans are referred to as “the other plans.”

  • Reduction in the plan’s benefits:

The benefits of this plan will be reduced when the total benefits payable exceeds the allowable expenses in a claim determination period. When the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan.

Right to receive and release needed information

Security Health Plan has the right to decide which facts it needs to apply these Coordination of Benefits (COB) rules. It may get needed facts from or give them to any other organization or person without the consent of the insured but only as needed to apply these COB rules. Medical records remain confidential as provided by federal and state law. Each person claiming benefits under this plan must give Security Health Plan any facts we need to pay claims.

 

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