Provider Manual
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Medicaid Managed Care
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Care Management
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Additional ProgramsChronic Care ManagementHealth AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsWellness and Health Promotion
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Claims Processing Policies and Procedures
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Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoordination 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 FormUnlisted CodesWhen Security Health Plan is primary bill for any serviceWorkers' Compensation
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Utilization Management
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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
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Family Health Center
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Claims Processing and Policies and Procedures
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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 FormUnlisted CodesWorkers Compensation
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Group & Direct Pay
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Claims Processing Policies and Procedures
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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 InstructionsUnlisted CodesWorkers' Compensation
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Pharmacy
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Utilization Management
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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 AdmissionLong 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
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Medicare Advantage
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Benefit Information
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Continuity and Coordination of CareCoverage Specifics for Certain ServicesDental BenefitsDepression in Primary Care GuidelinesEmergency and Urgently Needed Care CoverageHearing AidsHome INR MonitoringMacular Degeneration Eye InjectionsMental Health Medication ManagementPlan OverviewsPsychological TestingSkilled Nursing Facility
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Care Management
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Additional ProgramsAdvance Directive PolicyChronic Care ManagementCoverage 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
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Claims Processing Policies and Procedures
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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 FormUnlisted CodesWorkers' 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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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
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Utilization Management
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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
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Benefit Information
Workers' Compensation
Last Updated on April 29, 2022
- Security Health Plan does not cover the cost of services that are determined to be work related. Claims 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 a payment by the Workers’ Compensation carrier, the provider should submit 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 and 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.
- Upon notification that a member is pursuing a workers’ compensation court case, Security Health Plan will also enforce the workers’ compensation exclusion of the member’s benefit policy.
- Security Health Plan will reverse charges as allowed by the provider contract. The adjustment will be reflected on the provider’s reimbursement statement, using ANSI 19.
- For charges that Security Health Plan may not reverse, due to the provider contract, Security Health Plan may pursue those charges directly with Workers’ Compensation or an attorney. See the Subrogation page of the provider manual.
- 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 shp.work.comp@securityhealth.org.