Utilization management for behavioral health
Security Health Plan provides coverage of various mental health/AODA (alcohol and other drug abuse) benefits to individual, employer group or Medicare Advantage members. These benefits are managed by Security Health Plan. Members can seek care from any affiliated provider without primary care provider referral.
Behavioral health benefits renew on a calendar year basis and are divided into three benefit categories: inpatient, transitional, and outpatient services. Benefits are not interchangeable between categories.
Providers are encouraged to call Customer Service at 1-800-472-2363 to verify a member’s eligibility and benefits. To obtain the information by fax, use the fax number 715-221-9767.
Precertifications
- Precertification is required for all elective inpatient admissions and all admissions to residential treatment.
- To precertify inpatient elective admissions or transitional care services, fax 715-221-6616.
Authorizations
- Security Health Plan members may choose to see any affiliated provider.
- ALWAYS call to verify eligibility and benefits.
- Submit claims in a timely fashion.
- Security Health Plan requires the use of CPT coding.
- Security Health Plan requires the use of ICD-10 coding.
- Security Health Plan will deny claims if ICD-10 coding is not used.
- Security Health Plan will make a final claim decision after review of the claim, eligibility determination and determination of whether the service performed is a covered benefit under the policy.
Authorization of Inpatient Care Admission and Discharge
- Notification of emergent/urgent admissions and notification of discharge is required of the hospital within 24 hours or the next business day via fax.
- Security Health Plan Admission and Discharge fax number: 715-221-6616.
- Security Health Plan hours of operation are: Monday through Friday 7:30 a.m. – 5 p.m.
Security Health Plan provides coverage for medically necessary emergency care per the member's-contract limits. When the emergency results in an admission to an inpatient facility Security Health Plan requires the following information be submitted via fax at 715-221-6616. Information is required upon admission and again at discharge for authorization and payment for services. If the information is not received within the noted timeframes, payment for services will be denied to the provider. The following is the admission and discharge information required via fax to Security Health Plan:
Admission Information (within 24 hours or next business day)
- Admitting reason/ symptoms
- Updated demographic sheet
- Expected length of stay
Discharge Information (within 24 hours of discharge or next business day)
- Discharge plan
- Discharge diagnosis
- After care plan
- Follow up appointment Information (date, provider)
Facilities may fax documents containing the required information to Health Services at 715-221-6616.
Transitional Services
Transitional care is defined as services that are not as intensive as hospital inpatient, but more intensive than outpatient care. The State of Wisconsin mandate defines transitional services as:
- certified mental health and AODA day treatment programs
- certified mental health and AODA residential treatment programs (coverage is based on members benefit plan)
- certified community support programs
- intensive AODA outpatient programs provided in accordance with the patient placement criteria of the American Society of Addiction Medicine
- crisis intervention services
Affiliated Outpatient Services do not require notification
- Individual, group and family outpatient care does not require notification or prior authorization.
Authorizations of Residential Admission and Discharge
- Notification of residential admission and discharge is required of the hospital within 24 hours or the next business day via fax.
- Security Health Plan Admission and Discharge fax number: 715-221-6616.
- Security Health Plan hours of operation are: Monday through Friday 7:30 a.m. – 5 p.m.
Security Health Plan provides coverage for medically necessary care per the member's Evidence of Coverage.
Outpatient Services provided by an affiliated provider do not require notification
- Individual, group and family outpatient care does not require notification or prior authorization.
Attestation of noncompensation:
- Security Health Plan utilization management (UM) decisions are based on the use of nationally recognized and accepted clinical criteria and internal policy for determining appropriateness of care and availability of coverage.
- Security Health Plan does not specifically reward providers or other individuals for issuing denials of coverage.
- Security Health Plan does not have financial incentives in place for UM decision makers; therefore, UM decision makers are not encouraged to make decisions that result in underutilization.
How to access the medical director:
Affiliated providers may discuss a utilization management decision with the Security Health Plan Behavioral Health medical director by calling 1-800-548-1224.