Provider Manual
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BadgerCare Plus
- Benefit Information
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Care Management
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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
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Claims Processing Policies and Procedures
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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 ProtocolReimbursement Recovery ProcessSubrogationSurgery 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
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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 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
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Family Health Center
- Approved Outpatient Procedures
- Benefit Information
- Care Management
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Claims Processing and Policies and Procedures
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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 ProtocolReimbursement Recovery ProcessSubrogationTesting 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
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Group & Direct Pay
- Benefit Information
- Care Management
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Claims Processing Policies and Procedures
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Claims 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 InformationNew Code PricingOffice Infusion ProtocolOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- HCC - Risk Adjustement/Government Programs
- Important Disclosures
- Member Information
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Pharmacy
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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
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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 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
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Medicare Advantage
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Benefit Information
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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
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Care Management
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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
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Claims Processing Policies and Procedures
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Assigned RUG LevelsBilling and ReportingClaims Coding ResourcesCMS 1500 InstructionsCoding Quick ReferenceConsolidated Billing for Medicare Advantage Members Coordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityModifier InformationOffice Infusion ProtocolOrder of Benefit DeterminationOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationTesting 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
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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?
- Provider Directory
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Rights and Responsibilities
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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
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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
Prior Authorization
Certain prescription drugs require prior authorization (PA) from Security Health Plan before being covered under the Part D drug coverage. They appear on the formulary with the "PA" designation. Below is a list of drugs that require prior authorization with a brief description of the criteria used to make the coverage determination. In addition, there are other drugs on our formulary that require prior authorization to determine whether they are covered under Medicare Part B instead of Part D. To view the prior authorization criteria, please click here.
Providers or their agent(s) may initiate requests for formulary exceptions or authorizations via:
- Security Health Plan Pharmacy request line at 1-877-873-5611 or 715-221-9604
- Security Health Plan Pharmacy fax number at 715-221-9989
- Security Health Online (requires login with user name and password)
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.