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Provider Manual

Provider appeal and grievance policy

Last Updated on August 28, 2018

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 with any additional supporting documentation. If appeals are received without use of this form they will not be processed as a formal provider appeal.

Formal Provider Appeal form 

Submit post-service claim payment/denial appeals to:

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

Submit pre-service denial appeals to:

Mail to: Security Health Plan
            Attn: Medical Director
            P.O. Box 8000
            Marshfield, WI 54449-8000

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
  • Request reconsideration of 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

No post-service appeals may be submitted until the claim has been received and denied in full or in part. Any early appeals will be sent back to the provider with a letter stating that without a claim there is no denial and therefore no appeal can be considered.

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 reviewer 
  • The claim reviewer 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
  • 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
  • BadgerCare: Appeals must be submitted within 60 calendar days from the provider’s statement on which the charge was denied or reduced. 
  • Appeals must be complete and contain all pertinent information related to the case.  An appeal decision will be based only on the information submitted by the provider.
  • Appeals must be submitted using Security Health Plan’s ‘Formal Provider Appeal’ form located above. If this form is not used it will not be considered a formal appeal.
  • Appeals should contain any additional documentation to support why the original decision should be overturned. 
  • Completed appeals should be submitted through fax, email or mail as outlined above.
  • Formal appeals will be reviewed by the Security Health Plan Provider Appeals Committee.
  • Security Health Plan will respond in writing within 45 calendar days from the receipt of a complete appeal. For BadgerCare 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. 

Badgercare Plus appeals only 

  • 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 the State Department of Health Services 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 the State Department of Health Services must be submitted in writing within 60 days of Security Health Plan’s final decision. Submit completed appeals using ForwardHealth’s F-12022 (03/09) Wisconsin Medicaid and BadgerCare Plus Managed Care Program Provider Appeal Form to:
    ForwardHealth Managed Care Appeals
    P.O.  Box 6470
    Madison, WI 53716-0470
     
  • Visit ForwardHealth’s Topic 385 Appeals to BadgerCare Plus and Wisconsin Medicaid for further information on submitting an appeal to the State Department of Health Services.

Appeals related to pre-service 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 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.  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. 
    • retrospective review must be filed as a formal written appeal. 
  • Formal appeals must be submitted in writing within 60 days of the adverse determination, when the requested service has been provided. 
  • Formal appeals will be reviewed by the Security Health Plan Provider Appeals Committee.
  • Security Health Plan will respond in writing within 45 calendar days from the receipt of a complete appeal. For BadgerCare 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/ investigational. If the requesting or primary physician would like to discuss a case with a Security Health Plan medical director, call 715-221-9659.