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Provider Manual

Payment Issues

Last Updated on February 28, 2019

Federal Funds

The provider acknowledges that payments the provider receives from Security Health Plan to provide services to Medicare Advantage members are, in whole or part, from federal funds. Therefore, the provider and any of its subcontractors are subject to certain laws that are applicable to individuals and entities receiving federal funds, including but not limited to, Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR part 84; the Age Discrimination Act of 1975 as implemented by 45 CFR part 91; and the Americans With Disabilities Act.

Prompt Payment

Security Health Plan will reimburse non-affiliated providers within 30 days and affiliated providers within 60 days of receipt of a claim. Claims that require additional information or are subject to coordination of benefits will be paid promptly upon receipt of requested information.

Security Health Plan to apply MIPS to Medicare Advantage Claim Payments effective 1/1/2019

In alignment with CMS guidance, Security Health Plan will begin applying the Merit-based Incentive Payment System (MIPS) effective for Medicare Advantage claims date of service 01/01/19 and forward. MIPS will apply to service lines paid via the Medicare physician fee schedule (MPFS) and professional services billed on Critical Access Hospital - Method II claim lines if the rendering provider is eligible for a MIPS adjustment. Security Health Plan is applying both positive and negative MIPS adjustments to contracted and non-contracted provider payments. The MIPS adjustment amount can be identified on Security Health Plan Provider Statements with ANSI CO144, OA N807.

Per the CMS memo, based on their performance, MIPS eligible clinicians will receive a positive, neutral, or negative MIPS payment adjustment during the corresponding MIPS payment year. Performance in 2017 will be used to determine the MIPS payment adjustment that applies in the 2019 MIPS payment year.

References:
https://www.cms.gov/medicare/quality-payment-program/quality-payment-program.html