Provider Manual
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BadgerCare Plus
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Care Management
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Additional ProgramsChronic Care ManagementHealth Risk AssessmentNational 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 ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling limits Clean Claim Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsNon-Covered ServicesOptical 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 FormWhen Security Health Plan is primary bill for any serviceWorkers' Compensation
- Clinical Practice Guidelines
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- Documentation Requirements
- ForwardHealth
- HealthCheck
- Important Disclosures
- Member Information
- Product Overview
- Provider Directory
- Provider resources for Program Integrity Training
- 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 AdmissionSterilization: Hysterectomy CoverageLong 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
- Benefit Information
- Care Management
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Claims Processing and Policies and Procedures
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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 FormWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Important Disclosures
- Member Information
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Pharmacy
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Claims ProcessingDrug FormularyFormulary ExceptionGeneral ExclusionsGeneric SubstitutionNetwork PharmaciesOffice/Medical Setting Administered Medications that require prior authorization Over-the-counter Medication CoveragePrior AuthorizationStep TherapyTobacco Cessation CoverageUtilization Management
- 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 ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew 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
- Documentation Requirements
- 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 SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Over-the-Counter MedicationPrior AuthorizationStep TherapyTablet Splitting Incentive OptionTobacco Cessation CoverageUtilization Management
- Product Overview
- Provider Directory
- Rights and Responsibilities
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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 CoverageHearing AidsHome INR MonitoringMacular Degeneration Eye InjectionsMental Health Medication ManagementPsychological TestingSecurity Health Plan Copayment StructureSkilled Nursing Facility
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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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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 PaymentsLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- 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 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
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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
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.