Provider Manual

Provider appeal and grievance policy

Last Updated on October 06, 2026

All provider appeals must be submitted using Security Health Plan’s (SHP) Formal Provider Appeal form located below. The form must be complete and provide an explanation of why the services should be reviewed. Any supporting documentation should be included at the time of the appeal. SHP's appeal decision is based on the materials available at the time of formal appeal review. Any appeal that is received without this form, or with an incomplete form, will not be processed as a formal provider appeal.

Formal Provider Appeal form

Appeal related to post-service claim payments/denials

Providers have the ability to resubmit a claim (within timely filing guidelines), request reconsideration and/or appeal claim payments/denials.

Resubmit a claim: Submit a new claim with changed or added information that may result in a different claim determination. This is not a formal appeal. For more information on resubmitting a corrected claim, see Corrected claim or adjustment requests.
Request reconsideration of a claim: An informal verbal or written request for SHP to review a claim that the provider feels was incorrectly processed. This is not considered a formal appeal.
Appeal: A formal request for review of a claim determination when the provider does not agree with the claim reconsideration decision

Requesting reconsideration (requests for information regarding a claim payment/denial for services - this is not considered a formal appeal)

SHP will accept telephone or written requests
The request will be directed to the claim examiner
The claim examiner will answer the provider’s questions, investigate information, and attempt to resolve the issue with the provider
If the provider disagrees with the response given to the claim reconsideration, the provider may appeal by following the 'Requesting an appeal' section below.
If the provider identifies they have an error on the claim they may submit a corrected claim if within the timely filing window. For more information on resubmitting a corrected claim, see Corrected claim or adjustment requests .
While a reconsideration request can be submitted at any time SHP recommends they be done within appeal and claim resubmission timeframes to avoid missing these deadlines.

Requesting an appeal

No post-service appeals may be submitted until the claim has been received and denied in full or in part. If a finalized claim has not been received the appeal will be returned to the provider.

Commercial, TPA, FHC, Medicare Supplement products: Appeals must be submitted within 365 calendar days from the provider’s statement on which the charge was denied or reduced.

Medicare Advantage products: Appeals must be submitted within 65 calendar days from the provider’s statement on which the charge was denied or reduced.

Medicaid Managed Care products: Appeals must be submitted within 60 calendar days from the provider’s statement on which the charge was denied or reduced.

Appeal Process (all products):

Complete SHP’s Formal Provider Appeal form. If this form is not used, it will not be considered a formal appeal. Include all relevant information to support why the original denial should be overturned.
If you are a non-contracted provider appealing a post-service denial for our Medicare Advantage, Ally-Rx D-SNP or Secure Saver MSA plans, complete the Waiver of Liability form as required by section 50.1.1 of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.
Gather all documentation supporting why the claim is being appealed. SHP will not make any attempts to gather additional information or documentation from providers. Failure to submit complete documentation may lead to upholding of the original denial.
Completed appeals should be submitted via:

Fax: 715-221-9650
Email: shp.claims.provider.appeals-mfld@Sanfordhealth.org
Mail: Security Health Plan
Attn: Claims Department Appeals
P.O. Box 8000
Marshfield, WI 54449-8000
Appeals will be reviewed by SHP's Provider Appeals Committee.
SHP will respond in writing within 45 calendar days from the receipt (when it enters the SHP mail center) of a complete appeal. An appeal is considered a complete appeal when all requested information from SHP is received.
SHP’s response to the provider on appeals is final and will be in writing.

Medicaid Managed Care Programs appeals only

Providers are required to use SHP’s appeals process prior to initiating an appeal with the State.
If you disagree with SHP’s appeal determination, or SHP fails to respond to the appeal within 45 days, you may appeal the decision to the Department of Health Services (DHS).
- Providers are required to submit appeals with legible copies of all supporting documentation as outlined in the Appeals to BadgerCare Plus/Medicaid SSI HMOs and Children's Specialty Managed Care PIHPs (#384) and Appeals to ForwardHealth (#385) topics of the ForwardHealth Online Handbook.
Once all pertinent information is received, ForwardHealth has 45 calendar days to make a final decision. The provider and the HMO/PIHP will be notified by ForwardHealth of the final decision.
- To check on the status of an appeal submitted to ForwardHealth, providers can:
1. Access the Provider Appeals portal.
2. Call the ForwardHealth Managed Care Unit at 1-800-760-0001, option 1.
If ForwardHealth's decision is in favor of the provider, SHP will reprocess the impacted claim(s) for payment within 45 calendar days of the final determination.
ForwardHealth’s decision is final, and all parties are required to abide by the decision.

Non-contracted provider appeals for Medicare plans only

If SHP renders a partial or fully adverse decision, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare's Independent Review Entity (IRE). They will review the appeal within 60 calendar days to make sure the correct decision was made. You will receive correspondence by mail regarding their decision.

If the IRE renders a favorable decision for you, SHP must effectuate and comply with the IRE's decision. A new Remittance Advice will be sent to reflect the IRE's decision.

Appeals related to pre-service or medical necessity denials

Provider appeals related to adverse determination based on medical necessity

SHP denies coverage of a service or supply that is determined not medically necessary, not appropriate, or excluded because it is considered to be experimental or investigational. SHP uses nationally recognized criteria when making coverage determinations. A provider may appeal adverse determinations for prior authorization, pre-certification, referral authorization, or hospital stays in part or in total. When appealing an adverse determination, the request for a reconsideration of the adverse determination must be supported with additional information or written documentation from the medical record that was not previously reviewed by the SHP medical director. The medical director will at his/her discretion consult with like-specialty physicians.

Appeal process

Complete SHP’s Formal Provider Appeal form. If this form is not used or is incomplete, it will not be considered a formal appeal. Include all relevant information to support why the original denial should be overturned.
Formal appeals must be submitted in writing (with formal appeal form) within 60 days of the adverse determination, when the requested service has been provided.
Appeals must be complete and contain all pertinent information. An appeal decision will be based only on the information submitted by the provider.
Appeals related to:

a prospective review may be conducted via telephone with a medical director by calling 1-715-221-9659, option 1, or filing a written appeal when the requested service has not occurred.
a concurrent review should be directed per the expedited appeal policy. The provider may call the Health Services Department at 1-715-221-9659 and request an expedited appeal for concurrent review cases only. The member must currently be an inpatient. A decision will be made as expeditiously as the medical condition requires, but no later than 72 hours after the review commences.
a retrospective review must be filed as a formal written appeal.

Submit pre-service or medical necessity denial appeals by:
Email: shp.claims.provider.appeals-mfld@sanfordhealth.org
Mail: Security Health Plan
Attn: Claims Department Appeals
P.O. Box 8000
Marshfield, WI 54449-8000
Formal appeals will be reviewed by the SHP Medical Provider Appeals Committee.
SHP will respond in writing within 45 calendar days from the receipt of a complete appeal. For Medicaid Managed Care Program appeals, SHP will respond within 45 days from the date on the provider appeal form. An appeal is considered a complete appeal when all requested information from SHP is received.
SHP’s response to the provider on appeals is final and will be in writing.

Availability of medical directors

To ensure fair and consistent decision-making, providers have the opportunity to discuss with an SHP medical director denials that are based on medical necessity or considered to be experimental or investigational. If the requesting or primary physician would like to discuss a case with a SHP medical director, call 1-715-221-9659.