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Provider Manual

Utilization Management

Last Updated on January 24, 2019

Security Health Plan’s Health Services Department is composed of utilization management staff under the direction of the chief medical officer.

The utilization management staff routinely performs:

  • Precertification review of hospital admissions
  • Concurrent review of inpatient medical and behavioral-health admissions

    Note: Security Health Plan requires clinical information for concurrent review of inpatient and behavioral-health admissions for our members, regardless of whether Security Health Plan is the primary or secondary payer

  • Prior authorization for out-of-network care, home health care, skilled nursing facility and swing bed admissions 

  • Attestation of non-compensation:
    • Security Health Plan utilization management (UM) decisions are based on 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, nor does Security Health Plan make decisions regarding hiring, promoting or terminating individuals in UM decision-making based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.
    • 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 under utilization.
  • How to access the medical director:
    • Affiliated providers may discuss a utilization management decision with the Security Health Plan medical director by calling 715-221-9664Phone icon or 1-800-548-1224Phone icon.
  • How to access utilization management criteria:
    • Physicians and nurses at Security Health Plan use clinical criteria to make coverage decisions based on medical necessity. Nationally recognized guidelines that are modified with identification of those services available within the Security Health Plan network are used to make consistent decisions. Some examples of these guidelines are Hayes Medical Technology, InterQual Level of Care Criteria, American Society of Addiction Medicine, Wisconsin Uniform Placement Criteria, and Solucient. InterQual Level of Care Criteria are used to evaluate admission into inpatient and transitional services as well as for concurrent review. Hayes Medical Technology is used to identify those services that are considered to be experimental or investigational.
    • If seeing a Security Health Plan member and there are questions regarding the InterQual criteria used to make a determination of coverage, call Security Health Plan and receive a copy of the criteria at 1-800-548-1224, ext. 19659.

Security Health Plan will make a final claim decision after we review the claim, verify eligibility, and determine whether the service performed is a covered benefit under the policy.

FACILITIES TO DELIVER ORGANIZATION DETERMINATION APPROVAL NOTICES

When a Security Health Plan (SHP) Medicaid member is in a hospital (inpatient or observation status), the facility is required to provide notice of approvals and denials for services members request as part of the Organization Determination process.  The process is outlined below to help your staff deliver the approvals and denials.

Notice of Approved Benefit Determination

An approved benefit determination notice is provided to the requesting facility.

  • Notice includes a reference identifier and indicates the service to which the coverage has been applied.
  • When notice is required by law or per account contract to be provided to the member, it may be provided verbally, via secure internet portal or in writing.
  • The ordering and/or rendering provider/facility requesting the benefit on behalf of the member will be required to notify the member of approval and deliver a faxed copy of the approval.
  • Typically, the requestor is an ordering and/or rendering provider acting on behalf of the member. When verbal notice of an approval is given to the ordering and/or rendering provider, the provider is reminded to inform the member that the benefit has been approved by delivering the copy of the approval that SHP will fax to the requestor.  SHP will then documents the reminder and faxed approval in its system.

Notice of Adverse (Not Approved/ Not Certified) Benefit Determination

  • SHP may initially provide verbal notice of an adverse benefit determination to a member and ordering and/or rendering provider. 
  • SHP must follow up to provide written notice directly to the member and the ordering and/or rendering provider.
  • SHP staff will call members in the hospital to communicate the denial of service.  SHP then faxes the denial letter to hospital and instructs hospital staff to provide the paper copy of denial to the member.