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Provider Manual

Provider Remittance Advice Statement

Last Updated on August 28, 2018

Security Health Plan sends paper remittance advice statements to providers who elect to receive them. Providers may elect to receive remits electronically. All remittance advice statements, whether your practice elects electronic or paper statements, are available for viewing and printing through the Provider Portal.

Security Health Plan uses American National Standards Institute (ANSI) claim adjustment reason and remark codes. Codes can be viewed online at http://www.wpc-edi.com/content/view/695/1

Reimbursement statement example

Access the form   Reimbursement Statement Example

  1. Security Health Plan identifier
    1. Medicare Advantage HMO-POS
    2. Ally Rx Medicare Advantage D-SNP
    3. Medicare Advantage Secure Saver Medicare MSA
    4. BadgerCare – WI Medicaid Managed Care Program
    5. Family Health Center of Marshfield, Inc
    6. Medicare Supplement
    7. Security Administrative Services
    8. Security Health Plan
    9. Senior Security Medicare Select
  2. Practice or Provider name and address
  3. Security Health Plan group identifier
    1. Ally Rx Medicare Advantage D-SNP
    2. Commercial
    3. Commercial Central HPPN
    4. Commercial Central Qualified Health Plan
    5. Commercial Central
    6. Commercial Qualified Health Plan
    7. Commercial Valley
    8. Family Health Center
    9. Medicaid
    10. Medicare Advantage Core
    11. Medicare Advantage Southern
    12. Medicare Advantage Eastern
    13. Medicare Select
    14. Medicare Supplement with Riders
    15. Narrow Network
    16. Secure Saver Medicare MSA
  4. Statement Date
  5. Security Health Plan practice identifier - account number assigned to the practice by Security Health Plan for reporting payments at end of year.
  6. Capitated indicator– indicates if practice is paid on capitation.
  7. Last statement or Previous Balance – amount Security Health Plan paid on previous statement or previous balance due amount if practice was overpaid for services. Amount is specific to Security Health Plan group identifier (3).
  8. Last payment – amount of Security Health Plan payment on previous statement. Amount is specific to Security Health Plan group identifier (3).
  9. Charged amount – total amount billed by practice for all claims listed on statement.
  10. Allowed amount – total amount Security Health Plan allowed for all claims listed on statement.
  11. Provider responsibility – total amount of provider responsibility for all claims listed on statement. Provider responsibility can include totals of contractual obligation, denied charges, and other adjustments.
  12. Patient responsibility – total amount of patient responsibility for all claims listed on statement. Patient responsibility can include amounts applied to deductible, coinsurance and copays, and amounts denied to member as not covered.  Providers are entitled to receive payment from the patient for amounts applied to Patient responsibility.
  13. This payment or Balance due – total amount of payment Security Health Plan made for all claims on listed on statement or Balance due to Security Health Plan if practice was overpaid for services.
  14. Service date – date of service billed by practice for claim listed.
  15. Service code – code billed by provider for claim listed.
  16. Quantity – quantity or units billed by provider for claim listed.
  17. Charged amount – amount per line billed by provider for claim listed.
  18. Allowed amount – amount allowed per line by Security Health Plan for claim listed.
  19. Provider responsibility – amount per line Security Health Plan applied to provider responsibility.
  20. Provider ANSI – ANSI associated with Provider responsibility amount in 19.
  21. Patient responsibility – amount per line Security Health Plan applied to patient responsibility.
  22. Patient ANSI – ANSI associated with Patient responsibility amount in 21.
  23. Reimbursement – amount Security Health Plan paid per line.
  24. Patient name
  25. Member ID – Security Health Plan’s member identifier
  26. Subscriber ID – Security Health Plan’s subscriber number
  27. Claim number – Security Health Plan’s assigned claim number
  28. Patient account – account number assigned by the practice
  29. Patient totals – totals, per member, of Charged amount, Allowed amount, Provider responsibility, Patient responsibility, and Reimbursement
  30. Repricer used – identifies what Repricer was used to apply discounts
  31. Provider responsibility – ANSI codes and descriptions for each ANSI used on statement to apply amounts to provider responsibility
  32. Patient responsibility – ANSI codes and descriptions for each ANSI used on statement to apply amounts to patient responsibility
  33. Total provider responsibility – total amount applied to provider responsibility per ANSI followed by a total of all provider responsibility on statement
  34. Total patient responsibility – total amount applied to patient responsibility per ANSI followed by a total of all patient responsibility on statement
  35. Provider appeal rights and responsibilities – provides appeal rights, responsibilities, and timeframes for providers. Indicates Security Health Plan responsibilities related to appeals.