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Claims Processing Policies and Procedures
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Utilization Management
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Claims Processing Policies and Procedures
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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 managementUtilization 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 a payment by the Workers’ Compensation carrier, 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 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 of the Workers’ Compensation carrier denial. Security Health Plan may also pursue directly with Workers’ Compensation or an attorney if one has been retained.
- If a settlement has been made that results in the creation of a Medicare Set-aside Account, related charges will be denied. The adjustment will be reflected on the provider’s reimbursement statement, using ANSI P3. 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 P3.
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.