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Provider Manual

When Security Health Plan is primary bill for any service

Last Updated on January 24, 2019

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.