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Utilization Management
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Family Health Center
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Claims Processing and Policies and Procedures
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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
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Group & Direct Pay
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Claims Processing Policies and Procedures
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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
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Pharmacy
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Utilization Management
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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
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Benefit Information
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Care Management
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Claims Processing Policies and Procedures
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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
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Product Overview HMO and D-SNP
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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?
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Rights and Responsibilities
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Utilization Management
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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
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Benefit Information
Workers' Compensation
Last Updated on January 24, 2019
- Security Health Plan does not cover the cost of services covered by Workers’ Compensation. Claims that are determined to be work-related will be denied using ANSI code 19. The denial reason will print on the provider’s reimbursement statement. Claims must be submitted to the Workers’ Compensation carrier first.
- If claims have already been paid by Security Health Plan, related charges will be reversed. The adjustment will be reflected on the provider’s reimbursement statement, using ANSI 19.
- If the provider is overpaid due to payment from Workers’ Compensation, the provider should complete an adjustment request form and submit it with a copy of the original claim and a copy of the Explanation of Benefits from the Workers’ Compensation carrier. Security Health Plan will reverse charges. The adjustment will be reflected on the provider’s reimbursement statement.
- If the Workers’ Compensation carrier denies a claim, Security Health Plan will consider payment if a copy of the denial is attached. The provider must submit claims within 180 days from the date on the Workers’ Compensation carrier denial. Security Health Plan may pursue directly with Workers’ Compensation or an attorney if one has been retained.
- If the provider has any questions regarding Workers’ Compensation, please call 715-221-9503 or 1-800-548-4831, Monday through Friday between 8 a.m. and 4:30 p.m. or email shpcob@securityhealth.org.