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Provider Manual

Filing limits, Clean Claim and Interest Payments

Last Updated on August 28, 2018

Clean Claim Definition

A Clean Claim is complete, HIPPA compliant and on an accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to enable Security Health Plan to process the claim. A claim that does not meet the definition of a clean claim and requires investigation or additional documentation constitutes an unclean claim. The Clean Claim date is the date on which all such necessary information has been received.

Interest per Product

Security Health Plan will pay interest to the extent that interest would be owed under Wisconsin Stats Section 628.46. Please see below for product line & provider affiliation specifics. Interest will be calculated by Security Health Plan and paid on a per-claim basis. The amount paid per claim/claim line will be identified on the provider statement with ANSI code 225.

BadgerCare

  • Affiliated Providers: No interest paid
  • Non-affiliated Provider: Interest paid at 31 days

Commercial

  • Affiliated & Non-affiliated providers: Interest paid at day 31

Family Health Center

  • Affiliated Providers: No interest paid
  • Non-affiliated Providers: Interest paid at day 31

Medicare Advantage & Medicare Advantage DSNP/Ally

  • Affiliated providers: Interest paid at day 61
  • Non-affiliated providers: Interest paid at day 31

Medicare Advantage Secure Saver - MSA

  • All providers: Interest paid at day 31

Medicare Select/Senior Security

  • Affiliated Providers: No interest paid
  • Non affiliated Providers: Interest paid at day 31

Medicare  Supplement with Riders

  • All providers: Interest paid at date 31

Timely Filing per Product

Submitting claims to Security Health Plan as soon as possible after services occur is beneficial to both providers and members. Security Health Plan’s timely filing limits are outlined below based on product. When there is Coordination of Benefits (COB), claims must be submitted appropriately as indicated. Providers may not seek reimbursement from members for claims denied due to late submission.

Claim filing timelines do not end with the original claim submission. Providers who submit original claims to Security Health Plan within appropriate timeframes can submit corrected claims or adjustment requests within normal timely filing limits or 60 days from date of payment/denial/rejection, whichever is later. Resubmitted claims outside of normal timely filing limits or 60 days from date of payment/denial/rejection will be denied and cannot be resubmitted for payment.

BadgerCare 

  • Original claim submission: All providers have 365 days from the date of service.
  • Correction or adjustment claims: 365 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB: 365 days from the date of service or 60 days from date of primary payer’s statement, whichever is later.

Commercial

  • Original claim submission:
    • Affiliated providers have 180 days from the date of service.
    • Non-affiliated providers have 15 months from the date of service.
  • Correction or adjustment claims:
    • Affiliated providers have 180 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
    •  Non-affiliated providers have 15 months from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB:
    • Affiliated providers have 180 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
    • Non-affiliated providers have 15 months from the date of service or 60 days from date of payment/denial/rejection, whichever is later.

Family Health Center 

  • Original claim submission: 
    •  Affiliated providers have 365 days from the date of service.
  •  Correction or adjustment claims:
    • Affiliated providers have 365 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB:
    • Affiliated providers have 365 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.

Medicare Advantage & Medicare Advantage DSNP/Ally

  • Original claim submission: All providers have 365 days from the date of service.
  • Correction or adjustment claims: 365 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB: 365 days from the date of service or 60 days from date of primary payer’s statement, whichever is later.

Medicare Advantage Secure Saver – MSA

  • Original claim submission: All providers have 365 days from the date of service.
  • Correction or adjustment claims: 365 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB: 365 days from the date of service or 60 days from date of primary payer’s statement, whichever is later.

Medicare Select/Senior Security

  • Original claim submission: All providers have 180 days from the date of service.
  • Correction or adjustment claims: 180 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB: 180 days from the date of service or 60 days from date of primary payer’s statement, whichever is later.

Medicare Supplement with Riders

  • Original claim submission: All providers have 180 days from the date of service.
  • Correction or adjustment claims: 180 days from the date of service or 60 days from date of payment/denial/rejection, whichever is later.
  • COB: 180 days from the date of service or 60 days from date of primary payer’s statement, whichever is later.