Provider Manual
-
BadgerCare Plus
- Benefit Information
-
Care Management
-
Additional ProgramsChronic Care ManagementNational Committee for Quality AssurancePotentially Preventable Readmission programPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsTechnology AssessmentWellness and Health Promotion
-
Claims Processing Policies and Procedures
-
Claims Coding ResourcesCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNon-Covered ServicesOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementProvider Validation for Claims ProcessingReference 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
- ForwardHealth
- HealthCheck
- Important Disclosures
- Member Information
- Product Overview
- Provider Directory
- Rights and Responsibilities
-
Utilization Management
-
Acute Rehab AdmissionHigh end imaging and radiation servicesHospital admissions - pre-certificationHospital Observation AdmissionHysterectomies for fibroidsLong term acute care admissionPre-certification Notification and Concurrent Review GuideNaviHealth/Skilled Nursing Facility CareNorthwoodPrior Authorization for Non-affiliated ProvidersPrior authorizationProvider Appeal and Grievance PolicySecond OpinionServices Related to Oral AppliancesUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Family Health Center
- Approved Outpatient Procedures
- Benefit Information
- Care Management
-
Claims Processing and Policies and Procedures
-
Claims Coding ResourceCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference Outside Laboratory Billing ProtocolSubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Important Disclosures
- Member Information
- Pharmacy
- Program Overview
- Rights and Responsibilities
- Utilization Management
-
Group & Direct Pay
- Benefit Information
- Care Management
-
Claims Processing Policies and Procedures
-
Claims Coding ResourcesCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsFiling Limits, Clean Claim and Interest PaymentsElectronic File Submission ProcessLimitation of LiabilityModifier InformationOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- HCC - Risk Adjustement/Government Programs
- Important Disclosures
- Member Information
-
Pharmacy
-
Claims ProcessingDrug FormularyFormulary Exception Requests/Authorization RequestsGeneral ExclusionsGeneric SubstitutionMedications that require prior authorizationOver-the-Counter MedicationPrior AuthorizationStep TherapyTablet Splitting Incentive OptionTobacco Cessation CoverageUtilization Management
- Product Overview
- Provider Directory
- Rights and Responsibilities
- State of Wisconsin Employees
-
Utilization Management
-
Acute Rehab AdmissionDurable Medical Equipment and Home Respiratory EquipmentHigh End Imaging and Radiation ServicesHome IV Drug TherapiesHospice ProtocolsHospital Admissions - Pre-certificationHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionNaviHealthNorthwoodOutpatient Therapy Treatment ConcurrentPharmaceuticals - Specialty Medications (Magellan)Pre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Medicare Advantage
-
Benefit Information
-
Benefit ExplanationContinuity and Coordination of CareCoverage Specifics for Certain ServicesCovered BenefitsDental BenefitsDepression in Primary Care GuidelinesEmergency and Urgently Needed Care CoverageHome INR MonitoringMental Health Medication ManagementPsychological TestingSecurity Health Plan Copayment Structure
-
Care Management
-
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
-
Claims Processing Policies and Procedures
-
Billing and ReportingClaims Coding ResourcesCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityModifier InformationOrder of Benefit DeterminationOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolSubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- HCC - Risk Adjustement
- Important Disclosures
- Member Information
- Pharmacy
- Primary Care Provider
-
Product Overview HMO and D-SNP
-
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
-
Rights and Responsibilities
-
Access StandardsDocumentation of CareMedical policiesMedical Record Documentation StandardsProhibition 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
-
Utilization Management
-
Acute Rehab AdmissionAuthorization of Inpatient CareHigh End Imaging and Radiation ServicesHome IV Drug TherapiesHospital Admissions - Pre-certificationHospital Inpatient Utilization ReviewHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionNaviHealthNorthwoodPharmaceuticals - Specialty Medications (Magellan)Pre-Certification Notification and Concurrent Review GuidePrior Authorization for Nonaffiliated ProvidersPrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Benefit Information
Surgery Information
Last Updated on January 24, 2019
Multiple Surgery
Reimbursement will be made as follows:
- 100% of the maximum allowance fee for the primary procedure listed.
- 50% for the second through the fifth procedure.
- Each procedure after the fifth procedure will be considered on a case-by-case basis.
Exceptions to multiple procedures for a charge reduction are CPT codes, which by definition are always done and billed in conjunction with another procedure. These include codes described as “additional segments” or “second lesion.”
Bilateral Procedures
Unless otherwise identified in the listings in the CPT book, bilateral procedures that are performed at the same operative session should be identified by the appropriate five-digit code and modifier 50.
Bilateral procedures are paid based on the Medicaid Fee Schedule.
Assistants at Surgery
Assistants at surgery are covered when the assistant is considered medically necessary and appropriate. Criteria considered include the need for the expertise of another surgeon in a complicated case for decision-making or surgical involvement.
Reimbursement rate is based on the Medical Fee Schedule.
The multiple surgery reduction for subsequent procedures on the same day does apply to reimbursement for the assistant at surgery. When billing an assistant at surgery, use modifier 80 for a physician and modifier AS for a physician’s assistant or nurse practitioner.