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Claims Processing and Policies and Procedures
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Claims Processing Policies and Procedures
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Claims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingOffice Infusion ProtocolOrder of Benefit DeterminationOutput ReportsProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsWorkers' Compensation
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Utilization Management
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Claims Processing Policies and Procedures
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Billing and ReportingClaims Coding ResourcesClaims Payment CalendarCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityElectronic ClaimsElectronic File Submission ProcessFiling Limits, Clean Claim and Interest PaymentsLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormWorkers' Compensation
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Product Overview HMO and D-SNP
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Ally Rx D-SNP Model of CareDiscussion of Disenrollment from Medicare Advantage PlansEncounter Data PolicyMedicare Advantage Part D Data SubmissionsMedicare Advantage Part D Reporting RequirementsMedicare Advantage Reporting RequirementsRecipient of Federal Funds PolicyWhat are Medicare Advantage Plans?
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Utilization Management
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Acute Rehab AdmissionAuthorization of Inpatient CareeviCoreGeneral informationHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome IV Drug TherapiesHospital Admissions - Pre-certificationHospital Inpatient Utilization ReviewHospital Observation AdmissionHysterectomies for Diagnosis of FibroidsLong Term Acute Care AdmissionMusculoskeletal proceduresNaviHealthNorthwoodPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior Authorization for Nonaffiliated ProvidersPrior authorizationsProvider AppealRadiation Oncology ServicesSecond OpinionServices Related to Oral AppliancesSkilled Nursing Facility AdmissionSleep managementUtilization Management for Behavior HealthUtilization Management for Timeliness Standards
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Benefit Information
Claims Submission Test File Procedure
Last Updated on January 24, 2019
Once the username and password are assigned, the submitter can start sending claim transactions to the test environment. The test file may include any number of claims. Generally, trying to parallel a production run will yield the best test results. During the testing process, Security Health Plan will examine submitted test transactions for required elements, and will also ensure that the submitter gets a response during the testing mode. Security Health Plan will notify the provider upon the successful completion of testing.
When the submitter is ready to send an 837 transaction to the production mailbox, he/she must notify IS-Security Health Plan Development at 715-221-8340, and IS-Security Health Plan Development will move the submitter to the production environment. The submitter’s FTP username remains the same when moving from test to production. Passwords can be changed by the user in Personal Properties.
To submit a claim file:
- Go to the Security Health Plan website at the address http://www.securityhealth.org
- Single click on “File Transfers”
- A dialogue box will appear on the Web Browser entitled “The server bbs1.marshfieldclinic.org at BBS1 requires a username and password”. Enter in the username and password assigned by Security Health Plan.
- After entry of username and password, single click “OK” or hit enter
- Single click “File Libraries”
The file transfer page will appear. To send a file:
- Single click “Upload”
- Browse or type the file to be sent
- Single click “Upload Now”
To look at response reports:
- Single click “All files”
- Select the report to look at
- The reports will be available for 30 days
- The last response will not have a time stamp
Personal Properties can be changed and updated from the home page to reflect information such as address and company information. Also in Personal Properties the following information is displayed: messages written, number of calls, user date, last call, last new fields, downloads, uploads, expire date, account balance, and netmail balance. Personal Properties is where passwords can be changed and messaging data can be changed and updated.