Provider Manual

• Medicaid Managed Care
  • Benefit Information
    Dental and Oral SurgeryNever EventNon-covered ServicesNurse On-Call and Telemonitoring ProgramsPersonal Care ServicesSkilled Nursing FacilitySterilization - Hysterectomy CoverageSterilization - Tubal Ligation or Vasectomy CoverageTransportation ServicesUrgent Care & Emergency RoomVision care
  • Care Management
    Additional ProgramsChronic Care ManagementHealth Risk AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsWellness and Health Promotion
  • Claims Processing Policies and Procedures
    Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsOptical Eyewear Order GuidelinesOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Validation for Claims ProcessingProvider Remittance Advice StatementReimbursement Recovery ProcessReference 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
    Clinical Practice Guidelines
  • Contact Information
    Contact information
  • Documentation Requirements
    Telehealth Documentation RequirementsDocumentation of CareMedical Record Documentation
  • ForwardHealth
    ForwardHealth
  • HealthCheck
    BillingClinical PCP HealthCheck ReportsCodingExam at Community Based AgenciesExam DocumentationExam Including Prenatal ExamOutreachServicesVerification Card
  • Important Disclosures
    Confidentiality StatementNon-discrimination StatementProvider performance dataSuspension of Payment
  • Member Information
    Member HandbookRights and Responsibilities
  • Product Overview
    Overview
  • Provider Directory
    Provider Directory
  • Provider resources for Program Integrity Training
    Provider resources for Program Integrity Training
  • Rights and Responsibilities
    Access StandardsDHS Subcontract requirementsMedical PoliciesPrimary Care - Specialty Care Provider RoleProvider Credentialing ProcessProvider Reporting of Member ComplaintsProviders' Expectations of Security Health PlanSecurity Health Plans Expectations of Providers
  • Utilization Management
    Acute Rehab AdmissioneviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHospital admissions - pre-certificationHospital Observation AdmissionSterilization: Hysterectomy CoverageLong term acute care admissionMusculoskeletal proceduresNaviHealth/Skilled Nursing Facility CareNorthwoodNursing Facility Care/Skilled Nursing Facility CarePhysical, Speech and Occupational Therapy - OutpatientPre-certification Notification and Concurrent Review GuidePrior Authorization for Non-affiliated ProvidersPrior authorizationProvider Appeal and Grievance PolicySecond OpinionServices Related to Oral AppliancesSleep managementTechnology AssessmentUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
• Family Health Center
  • Benefit Information
    Ambulance TransportationDental and Oral SurgeryEmergency RoomInpatient, Outpatient and Ambulatory Surgery CenterMental Health and Substance Use DisorderNon-covered servicesNurse On-call ProgramPrescription Medications/PharmacySterilizationTobacco Cessation
  • Care Management
    Additional ProgramsWellness and Health Promotion
  • Claims Processing and Policies and Procedures
    Claims Coding ResourceClaims Payment CalendarCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference Outside Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormWorkers Compensation
  • Clinical Practice Guidelines
    Clinical Practice Guidelines
  • Contact Information
    Contact Information
  • Documentation Requirements
    Telehealth Documentation RequirementsDocumentation of CareMedical Record Documentation
  • Important Disclosures
    Confidentiality StatementNon-discrimination StatementProvider performance data
  • Member Information
    Member information
  • Pharmacy
    Claims ProcessingDrug FormularyFormulary ExceptionGeneral ExclusionsGeneric SubstitutionNetwork PharmaciesOffice/Medical Setting Administered Medications that require prior authorization Prior AuthorizationStep TherapyTobacco Cessation CoverageUtilization Management
  • Program Overview
    Program Overview
  • Rights and Responsibilities
    Access StandardsFamily Health Center Expectations of ProvidersMedical PoliciesProvider Credentialing ProcessProvider Reporting of Member ComplaintsProviders' Expectation of Family Health Center
  • Utilization Management
    High end imaging and radiation servicesHospital Admissions - Pre-certificationHysterectomies for diagnosis of fibroidsLong Term Acute Care AdmissionNorthwoodPrior authorizationsProvider Appeal and Grievance PolicySecond Opinion
• Group & Direct Pay
  • Benefit Information
    Dental Oral SurgeryEmergency/Urgent Care ServicesHearing AidsNever EventsNon-Covered ServicesPreventive benefitsTemporomandibular (TMD) DisorderVision Care
  • Care Management
    Additional ProgramsChronic Care ManagementTransition Care ManagementWellness and Health Promotion
  • Claims Processing Policies and Procedures
    Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingOffice Infusion ProtocolOrder of Benefit DeterminationOutput ReportsPrior Authorization Required for Office Based Procedures in ASC or Hospital Outpatient SettingProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsWorkers' Compensation
  • Clinical Practice Guidelines
    Clinical Practice Guidelines
  • Contact Information
    Contact Information
  • Documentation Requirements
    Documentation of CareMedical Record DocumentationTelehealth Documentation Requirements
  • HCC - Risk Adjustment/Government Programs
    HCC - Hierarchical Condition Category Coding
  • Important Disclosures
    Confidentiality StatementNondiscrimination StatementProvider performance dataSuspension of Payment
  • Member Information
    ID Card SampleMember HandbookRights and Responsibilities
  • Pharmacy
    Claims ProcessingDrug FormularyFormulary Exception RequestsGeneral ExclusionsGeneric SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Prior AuthorizationStep TherapyTobacco Cessation CoverageUtilization ManagementOver-the-Counter Medication Coverage
  • Product Overview
    Product Overview
  • Provider Directory
    Provider Directory
  • Rights and Responsibilities
    Access StandardsMedical PoliciesProvider Credentialing ProcessProvider Reporting of Member ComplaintsProviders' Expectations of Security Health PlanSecurity Health Plan's Expectations of Providers
  • Utilization Management
    Acute Rehab AdmissionDurable Medical Equipment and Home Respiratory EquipmenteviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome IV Drug TherapiesHospice ProtocolsHospital Admissions - Pre-certificationHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionMusculoskeletal proceduresNaviHealthNorthwoodOutpatient Therapy Treatment ConcurrentPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization 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 CoverageHearing AidsHome INR MonitoringMacular Degeneration Eye InjectionsMental Health Medication ManagementPsychological TestingSecurity Health Plan Copayment StructureSkilled Nursing Facility
  • 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 ProtocolsTwo Midnight RuleWellness and Health PromotionOutpatient Observation Frequently Asked Questions
  • Claims Processing Policies and Procedures
    Billing and ReportingClaims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsGenetic and Molecular Lab TestingLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementRate Letters from CMS for CAH, RHC & Swing BedsReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormWorkers' Compensation
  • Clinical Practice Guidelines
    Clinical Practice Guidelines
  • Contact Information
    Contact Information
  • Documentation Requirements
    Documentation of CareMedical Record DocumentationTelehealth Documentation Requirements
  • HCC - Risk Adjustment
    HCC - Hierarchical Condition Category Coding
  • Important Disclosures
    Confidentiality StatementNondiscrimination StatementProvider performance dataSuspension of Payment
  • Member Information
    Appeal/GrievanceCustomer Service RepresentativesEligibility and Enrollment Evidence of Coverage/Member HandbookID Card SampleMember Rights and Responsibilities
  • Pharmacy
    Exception ProcessAppeal ProcessCoverage DeterminationFormularyMedications that require prior authorizationPrescription ToolsPrior Authorization
  • Primary Care Provider
    Anti-kickback StatuteCompliance - Fraud, Waste and AbuseModel of CareThe False Claims Act
  • 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
    Provider Directory
  • Rights and Responsibilities
    Access StandardsMedical policiesProhibition 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 CareeviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome IV Drug TherapiesHospital Admissions - Pre-certificationHospital Inpatient Utilization ReviewHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionMusculoskeletal proceduresNaviHealthNorthwoodPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior Authorization for Nonaffiliated ProvidersPrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization Management for Behavior HealthUtilization Management for Timeliness Standards