Provider Manual
-
BadgerCare Plus
- Benefit Information
-
Care Management
-
Additional ProgramsChronic Care ManagementNational Committee for Quality AssurancePotentially Preventable Readmission programPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsTechnology AssessmentWellness and Health Promotion
-
Claims Processing Policies and Procedures
-
Claims Coding ResourcesCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNon-Covered ServicesOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementProvider Validation for Claims ProcessingReference 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
- Contact Information
- ForwardHealth
- HealthCheck
- Important Disclosures
- Member Information
- Product Overview
- Provider Directory
- Rights and Responsibilities
-
Utilization Management
-
Acute Rehab AdmissioneviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHospital admissions - pre-certificationHospital Observation AdmissionHysterectomies for fibroidsLong term acute care admissionMusculoskeletal proceduresNaviHealth/Skilled Nursing Facility CareNorthwoodPhysical, 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 managementUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Family Health Center
- Approved Outpatient Procedures
- Benefit Information
- Care Management
-
Claims Processing and Policies and Procedures
-
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
- Clinical Practice Guidelines
- Contact Information
- Important Disclosures
- Member Information
- Pharmacy
- Program Overview
- Rights and Responsibilities
- Utilization Management
-
Group & Direct Pay
- Benefit Information
- Care Management
-
Claims Processing Policies and Procedures
-
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
- Clinical Practice Guidelines
- Contact Information
- HCC - Risk Adjustement/Government Programs
- Important Disclosures
- Member Information
-
Pharmacy
-
Claims ProcessingDrug FormularyFormulary Exception Requests/Authorization RequestsGeneral ExclusionsGeneric SubstitutionMedications that require prior authorizationOver-the-Counter MedicationPrior AuthorizationStep TherapyTablet Splitting Incentive OptionTobacco Cessation CoverageUtilization Management
- Product Overview
- Provider Directory
- Rights and Responsibilities
- State of Wisconsin Employees
-
Utilization Management
-
Acute Rehab AdmissionDurable Medical Equipment and Home Respiratory EquipmenteviCoreHigh 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 managementUtilization 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 CoverageHome INR MonitoringMacular Degeneration Eye InjectionsMental Health Medication ManagementPsychological TestingSecurity Health Plan Copayment StructureMacular Degeneration Eye Injections
-
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 ProtocolsTechnology AssessmentTwo Midnight RuleWellness and Health PromotionOutpatient Observation Frequently Asked Questions
-
Claims Processing Policies and Procedures
-
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
- Clinical Practice Guidelines
- Contact Information
- HCC - Risk Adjustement
- Important Disclosures
- Member Information
- Pharmacy
- Primary Care Provider
-
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
-
Rights and Responsibilities
-
Access StandardsDocumentation of CareMedical policiesMedical Record Documentation StandardsProhibition 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 CareeviCoreHigh 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 managementUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Benefit Information
Hospital Inpatient Utilization Review
Last Updated on January 24, 2019
- Medicare Advantage members admitted to “Hospital Inpatient” status must meet InterQual inpatient criteria for the hospital to receive inpatient reimbursement.
- When Medicare Advantage members are admitted to “Hospital Outpatient Observation” status as defined by Medicare, hospitals will receive reimbursement for the stay per Medicare outpatient observation guidelines.
- The physician services provided to Medicare Advantage members, whose inpatient hospitalization has been denied due to the lack of inpatient criteria, will not be reimbursed.
Providers are responsible for determining the medical necessity for a Security Health Plan Medicare Advantage member to be hospitalized as “inpatient” or “observation.” Security Health Plan uses InterQual criteria to review hospital inpatient admissions for medical necessity. In cases where inpatient criteria are not met, Security Health Plan will not reimburse for the inpatient DRG, per diem rate (Critical Access Hospital), or physician services.
Security Health Plan has identified some hospital admissions that do not meet inpatient InterQual criteria. In these cases, the members’ conditions lacked severity of illness, or the level of service provided lacked intensity. Medicare may reimburse for these situations under “Hospital Observation” status, if the physician admits the recipient to “Hospital Observation” status and bills for such outpatient observation services. Security Health Plan also reimburses for “Hospital Observation” status per Medicare guidelines and reimbursement rates for eligible members.The physician’s admission order must clearly indicate whether the admission is for “Inpatient Hospital” or “Hospital Observation” status.
Medicare information is available on the Centers for Medicare and Medicaid Services (CMS) web site at
www.cms.hhs.gov.
If you have additional questions, please contact your Security Health Plan provider network specialist at 1-800-548-1224 or 715-221-9588.