Provider Manual
-
Medicaid Managed Care
- Benefit Information
-
Care Management
-
Additional ProgramsChronic Care ManagementHealth AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsWellness and Health Promotion
-
Claims Processing Policies and Procedures
-
Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsOptical Eyewear Order GuidelinesOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Validation for Claims ProcessingProvider Remittance Advice StatementReimbursement Recovery ProcessReference outside Laboratory Billing ProtocolSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWhen Security Health Plan is primary bill for any serviceWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- ForwardHealth
- HealthCheck
- Important Disclosures
- Member Information
- Product Overview
- Provider Directory
- Provider resources for Program Integrity Training
- Rights and Responsibilities
-
Utilization Management
-
Acute Rehab AdmissioneviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHospital admissions - pre-certificationHospital Observation AdmissionSterilization: Hysterectomy CoverageLong term acute care admissionMusculoskeletal proceduresNaviHealth/Skilled Nursing Facility CareNorthwoodNursing Facility Care/Skilled Nursing Facility CarePhysical, 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 managementTechnology AssessmentUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Family Health Center
- Benefit Information
- Care Management
-
Claims Processing and Policies and Procedures
-
Claims Coding ResourceClaims Payment CalendarCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsOrder 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 FormUnlisted CodesWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- 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 ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingOffice Infusion ProtocolOrder of Benefit DeterminationOutput ReportsPrior Authorization Required for Office Based Procedures in ASC or Hospital Outpatient SettingProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- HCC - Risk Adjustment/Government Programs
- Important Disclosures
- Member Information
-
Pharmacy
-
Claims ProcessingDrug FormularyFormulary Exception RequestsGeneral ExclusionsGeneric SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Over-the-Counter Medication CoveragePrior AuthorizationSpecialty pharmacyStep TherapyTobacco Cessation CoverageUtilization Management
- Product Overview
- Provider Directory
- Rights and Responsibilities
-
Utilization Management
-
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 AdmissionLong 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 managementTechnology AssessmentUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Medicare Advantage
-
Benefit Information
-
Continuity and Coordination of CareCoverage Specifics for Certain ServicesDental BenefitsDepression in Primary Care GuidelinesEmergency and Urgently Needed Care CoverageHearing AidsHome INR MonitoringMacular Degeneration Eye InjectionsMental Health Medication ManagementPlan OverviewsPsychological TestingSkilled Nursing Facility
-
Care Management
-
Additional ProgramsAdvance Directive PolicyChronic Care ManagementCoverage 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 ProtocolsTwo Midnight RuleWellness and Health PromotionOutpatient Observation Frequently Asked Questions
-
Claims Processing Policies and Procedures
-
Billing and ReportingClaims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsGenetic and Molecular Lab TestingLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementRate Letters from CMS for CAH, RHC & Swing BedsReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- HCC - Risk Adjustment
- 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 StandardsMedical policiesProhibition 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 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 managementTechnology AssessmentUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
-
Benefit Information
Medicare Advantage Part D Data Submissions
Last Updated on January 24, 2019
Prescription drug event data - As a Medicare Advantage Part D plan, Security Health Plan is required to submit Part D drug claims data to CMS. For each Part D dispensing event, Security Health Plan shall submit a summary record called the prescription drug event (PDE) record to CMS. The PDE record contains prescription drug cost and payment data that will enable CMS to make payment to plans and otherwise administer the Part D benefit. Specifically, the PDE record will include covered drug costs above and below the out-of-pocket threshold; distinguish enhanced alternative costs from the costs of drugs provided under the standard benefit; and will record payments made by Part D plan sponsors, other payers, and by or on behalf of beneficiaries. Security Health Plan shall also identify costs that contribute towards a beneficiary’s true-out-of-pocket or TrOOP limit, separated into three categories: low-income cost-sharing subsidy amounts paid by the plan at the point of sale, beneficiary payments, and all TrOOP-eligible payments made by qualified entities on behalf of a beneficiary.