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Provider Manual

Programs for Members

Last Updated on August 23, 2018

Health Services Department 

Security Health Plan’s Health Services Department is responsible for the assessment, care coordination and management of the health care needs of members. This is accomplished through health-risk assessment, case management, disease management and health-education programs. 

The Health Services Department is staffed with medical directors, registered nurses, social workers, physical therapist, pharmacist, health educators and administrative staff. 

  • Utilization management process, denial or other inquiries should be directed to the Security Health Plan Health Services Department at 1-800-991-8109.
  • Quality-management inquiries should be directed to 1-800-548-1224.

Availability of medical directors 

To ensure fair and consistent decision making, providers may discuss with Security Health Plan medical directors those denials that are based on medical necessity or considered to be experimental/investigational. If the requesting or primary physician would like to discuss a case with a Security Health Plan medical director, call Provider Assistance Line at 1-800-548-1224. 

Disease Management 

Security Health Plan’s personal approach to disease management emphasizes local support from certified professionals with years of clinical experience in their field. Security Health Plan provides disease management for members with diabetes, asthma, heart failure and depression. Members receive educational information, and have the option to receive telephonic coaching with a nurse or social worker to help them learn how to take greater control of their own condition. 

Program features: 

  • Convenient – Programs are delivered via mailed information or telephone contacts. The enrollee does not have to travel to participate.
  • Comprehensive – We focus on health issues specific to each individual.
  • Collaborative – Our process promotes a team approach including members, providers, nurses and other professionals.
  • Coaching – Registered nurses and social workers use a motivational approach to promote behavior change for optimal health.
  • Tailored approach – We customize our approach based on an individual’s health.

Program goals: 

  • Improve member health
  • Provide high-quality health care
  • Change behavior
  • Empower members to manage their condition
  • Prevent health complications
  • Contain health care cost

These initiatives are provided to members at no additional charge. 

Heart Failure program 

The Heart Failure program encourages self-management, development of positive relationships with medical care providers and caregivers, and encourages appropriate utilization of resources to achieve the best heart health possible. Members receive mailed information about heart failure and one-on-one consultation with a nurse coach, who works closely with members and providers to identify exacerbation symptoms early and avoid unnecessary emergency visits and hospitalizations. The program is based on the Institute of Clinical Systems Improvement (ICSI) guidelines. 

Members in this program will learn the benefits of: 

  • Understanding heart failure
  • Monitoring daily weight/symptoms
  • Adhering with medications
  • Eating healthy
  • Quitting tobacco
  • Exercising

Blood pressure and cholesterol control 

Security Health Plan identifies members with high blood pressure and high cholesterol early so we can educate them on the importance of proper treatment. We also offer nurse coaching services to help members better understand their health condition and what they can do to improve it. 

Asthma Management program 

Members learn how to control their asthma symptoms by working with a certified asthma nurse educator as part of the Asthma Management program. Members learn about the diagnosis and treatment of adult and childhood asthma. Members learn the importance of self-management as they receive one-on-one education and use asthma care kits as part of the program. 

The Asthma Management program is based on the Institute of Clinical Systems Improvement (ICSI) guidelines. This guideline recommends primary care provider follow-up after an asthma-related emergency room or urgent care visit or hospitalization. The need for asthma care in these settings is often an indication of uncontrolled asthma. 

Members in this program will learn how to: 

  • Understand and correctly administer medications
  • Manage asthma triggers
  • Use the asthma care kit
  • Monitor and control asthma attacks
  • Complete and follow an asthma action plan
  • Use a peak flow meter/spacer
  • Quit tobacco

Diabetes Management program 

The foundation of a successful Diabetes Management program is member and provider compliance with guideline recommendations for good diabetes care. Security Health Plan’s Diabetes Management program emphasizes communication among members with diabetes, their providers and Security Health Plan to increase compliance and improve members’ health. 

The educational information Security Health Plan provides for its members is based on the clinical practice recommendations of the Institute of Clinical Systems Improvement (ICSI) guidelines. 

Members in this program will learn the benefits of: 

  • Receiving recommended diabetes testing
  • Healthful eating
  • Quitting tobacco
  • Exercising
  • Monitoring and controlling blood-sugar levels

Out of the Blue program 

Depression requires multi-faceted management to assure effective treatment. The Out of the Blue program provides education to members who are diagnosed with depression and receive treatment with antidepressant medication. 

The program is based on the nationally recognized, evidence-based IMPACT study and the DIAMOND Project, which both have proven success achieving optimal management of the treatment of depression. Unlike other depression-management programs, Security Health Plan uses on-staff social worker care managers who work closely with members to improve their understanding of depression, how to use their medication and coping strategies. 

Expect Your Best 

Prenatal education and support reduce the risk of complicated births. Members receive information on the value of prenatal care and strategies to ensure a healthy birth outcome. Nurse care managers can work with members experiencing high-risk pregnancies and their physicians to reduce the risk of complications and improve the rate of healthy births. 

Strong mental health during and after pregnancy ensures new mothers and their babies get a healthy emotional jump-start. The evidence-based Edinburgh Post-partum Depression Scale is mailed to members three times during their pregnancy as well as soon after the birth. Our social worker care managers contact members whose scores point toward depression, and offer the Out of the Blue program to the member. Key components of success in this program are for members to receive personalized support, and that the provider is alerted to the member’s needs. 

Tobacco-Free program 

Security Health Plan supports members who want to quit using tobacco. We offer full coverage for all FDA-approved tobacco-cessation medications for most members when a provider prescription is obtained. People who get support and education when quitting are more likely to be successful. We offer up to six phone sessions designed to help members develop a plan to quit and go over topics such as: 

  • Preparing to quit
  • Behavior, habits and addiction
  • Managing stress
  • Living a healthy life
  • Remaining tobacco free

Online wellness programs

Security Health Plan and WebMD have online resources to help you manage your health. Start your journey to better health by visiting www.securityhealth.org/live-healthier.  

Health assessment
The health assessment asks basic questions about your diet, exercise, sleep, health history and lifestyle. In about 10-minutes you will receive a complete picture of your health and a plan to help reach your best self. You can also talk with a health coach to get the support and advice you need to move forward with your health and wellness goals.

My Digital Health Assistant
You’ve taken your health assessment. You’ve received your personalized action plan. Great. Now start reaching your goals with your online Health Assistant.  Whether you want to lose weight, quit tobacco, manage stress exercise more, or boost your mood, your Health Assistant has a plan for you. Take it one step at a time by setting small goals and tracking your progress along the way. All tips come from WebMD expert health coaches and you can track your progress using your smartphone or tablet.

Here are a few additional perks you will find:

Symptom Checker – Use the interactive symptom checker to see what could be causing your symptoms. Learn about causes, treatments and related conditions.

Health Topics provides you with and in-depth assessments and information about specific health conditions like depression, chronic fatigue and diabetes.

Mobile Applications – Health in the palm of your hand. Check out mobile apps that will help you begin and sustain an exercise habit, lose weight and maintain that weight loss. Transform small steps into healthy habits that last a lifetime.

And More – Watch videos covering emerging health trends, try out hundreds of healthy recipes with preparation tips and nutritional information, and complete brief interactive health-related questionnaires and calculators.

Care management 

One-on-one support, which focuses on each member’s specific health care needs, is the focus of Security Health Plan’s Care Management services. Our certified professionals, which include physicians, registered nurses, social workers, a physical therapist and a pharmacist help coordinate a member’s individual health care needs with primary physicians, other health care professionals and community services. Case managers provide an array of services to help individuals and families effectively cope with complicated situations. 

Care management provides the following value to members at no added cost: 

Helps members with complex health care needs such as: 

  • Cancer
  • Transplants
  • Serious trauma
  • Chronic illness that results in high use of medical services
  • Behavioral health conditions
  • Nutritional needs
  • Stroke
  • Uncontrolled pain
  • Spinal injuries
  • AIDS
  • Multiple chronic illness

Helps reduce hospitalizations 

After a hospitalization, Security Health Plan Care Management staff may follow up with members to make sure they knows how to care of themselves once they are at home, understand when and how to take their medications and when to receive follow up care from their primary care provider. 

Security Health Plan Care Management services are also available for members with safety concerns, home management and medication management difficulties after discharge from the nursing home. 

Provides education and extensive support in self-care, such as: 

  • Advance directives
  • Hospice and home health
  • Caregiver role strain
  • Medication management
  • Tobacco cessation
  • Difficulty navigating the medical system for follow-up medical care or making appointments

Physicians, other health care professionals, Security Health Plan staff, agents, members or family members may refer members for Care Management services by calling Customer Service at 1-800-472-2363. Security Health Plan staff also review 24-hour Nurse Line calls, emergency room visits and health-risk assessments to identify members who would benefit from Care Management telephonic services. 

 24-hour Nurse Line 

1-800-549-3174 

Security Health Plan has a phone line, staffed by registered nurses, available to members 24 hours a day, 7 days a week. The nurses servicing the phone line are specially trained in triage and are ready to discuss health-related questions and concerns. When a member calls, a nurse will: 

  • Listen to health concerns and questions
  • Offer information and medical advice
  • Discuss options for care
  • Provide follow-up as appropriate

The nurses use guidelines approved by physicians to advise members as to what type of care they may need: self-care, physician appointment, urgent care or emergency care. The nurses offer advice. The final decision regarding type of care is always the choice of the member. 

Nurse navigator 

A nurse navigator is a registered nurse, supported by medical directors, who works across the health care system to help members receive the right care at the right time. A nurse navigator can assist members in managing their health care resources and act proactively on their behalf. The goal is to enhance the quality of care members receive by helping them navigate through a complex health care system. 

Through one-on-one, personalized support, here are just a few of the things a nurse navigator can do: 

  • Research questions and coordinate care related to medical conditions
  • Provide information on benefits and insurance coverage
  • Help improve the communication between your provider and you
  • Help you explore provider and/or treatment options
  • Assist you in understanding your benefits and the prior authorization process
  • Listen to and coach you through difficult decisions

One call to Security Health Plan’s Customer Service Department 1-800-472-2363 puts a member in touch with a nurse navigator. 

Member advocate 

1-800-472-2363 

Security Health Plan has an advocate on staff to assist members. The member advocate is your contact in the event of a formal grievance, but is primarily available to help answer questions and solve problems that may prevent a grievance from becoming necessary. It is the advocate’s job to assure member access to care and quality of care, and to help the member overcome barriers he or she might encounter within Security Health Plan or the provider network. The advocate is responsible for ensuring members receive culturally sensitive care. The advocate is available to any Security Health Plan member. Providers may call the advocate for assistance with any Security Health Plan members.