Prior Authorization for Nonaffiliated Providers
Contact Security Health Plan before a Medicare Advantage member is referred to a nonaffiliated provider.
Security Health Plan does not cover care received from nonaffiliated providers without prior authorization from the Security Health Plan medical director except for emergency or urgent care as described in the emergency medical care/urgent care sections of this manual. If a provider feels a Security Health Plan member needs to see a provider who is not affiliated with Security Health Plan, the provider or the patient must call Security Health Plan for approval before the member’s visit with the nonaffiliated provider. If Security Health Plan does not approve the referral, services with the nonaffiliated provider will not be covered under the member’s policy, and the member will be responsible for paying all costs of the visit.
Please note: The Security Health Plan prior authorization requirements apply regardless of whether or not Security Health Plan is the member’s primary or secondary coverage. If the claim will eventually be billed to Security Health Plan (whether primary or secondary), prior authorization will be required for payment.
Prior authorization requirements apply to all Security Health Plan coverage lines: Security Health Plan Medicare products, Security Administrative Services (SAS), Security Health Plan BadgerCare Plus, large and small employer plans and individual and family plans both on and off the Federally-facilitated Marketplace.
Prior authorization requirements apply to services requested directly from Security Health Plan and to those requested from vendors contracted by Security Health Plan such as, but not limited to, eviCore, NaviHealth, Magellan or Northwood for Security Health Plan members.
Prior authorization should be sought for workers’ compensation/liability cases, to avoid denials in the event workers’ compensation/liability coverage is denied or exhausted.
If a Security Health Plan member is being seen for an injury believed to be work-related and covered by workers’ compensation, the services should be prior authorized at the same time the service is provided, to ensure coverage in the event the workers’ compensation claim is denied.
For quickest response, file a Prior Authorization Request online. Here's how:
- Go to www.securityhealth.org
- Enter your user name and password. (If you do not have a user name and password, you may obtain one by completing the Provider Portal Access Request Form available on Security Health Plan's website by selecting “Providers,” “Electronic Data Interchange,” and "Provider Portal Access Request.”)
- Select Authorization Request.
- Select Medical Request.
- Enter member information.
- Under Requested Service/Procedure field, select Nonaffiliated Provider Authorization Request.
- When filling out the prior authorization request, be sure to include all CPT codes for the procedure(s) and the medical reason why a site-of-service exception is being requested for the specific office procedure(s).
You can also contact Security Health Plan’s Health Services Department at 1-877-998-0998 to request a prior authorization to refer a member to a provider out of Security Health Plan's affiliated network. The coordinator will need the following information:
- Member name and Security Health Plan subscriber number
- CPT and ICD 10 codes as appropriate
- Provider and/or facility the member is being referred to
- Has the member seen this provider in past? When?
- Is the appointment or service scheduled? If yes, for what date has it been scheduled?
- Service being requested (for example, consult only, initiate treatment or assume ongoing care) or the referral request may be submitted on a Nonaffiliated Prior Authorization form.
- Explanation of why member cannot receive services from a Security Health Plan affiliated provider.
- The prior authorization may also be requested electronically via the Provider Portal as noted above.
- Provide supporting medical records with the request as appropriate.
- Failure to cooperate with the plan’s referral policies and procedures may constitute “good cause” for termination under the “Term and Termination” sections of the provider and facility contracts.
A Security Health Plan medical director will consider approval of prior authorization requests for nonaffiliated providers only if all of the following requirements are met:
- The services are medically necessary
- The services are a covered benefit
- The services are not available from an affiliated provider
- The services are received from a Security Health Plan approved referral provider