Provider Manual
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Medicaid Managed Care
- Product Overview
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Benefit Information
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Clinical Trials and Related Routine ServicesDental and Oral SurgeryHome Health Care ServicesNever EventNon-covered ServicesNurse On-Call and Telemonitoring ProgramsPersonal Care ServicesSkilled Nursing FacilitySterilization - Hysterectomy CoverageSterilization - Tubal Ligation or Vasectomy CoverageTransportation ServicesUrgent Care & Emergency RoomVision care
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Care Management
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Additional ProgramsChronic Care ManagementHealth AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPrenatal Care Coordination ServicesPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsWellness and Health Promotion
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyBilling claims for dates that span a change of enrollmentClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsOutput ReportsProvider Appeal and Grievance PolicyProvider Validation for Claims ProcessingProvider Remittance Advice StatementReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessReference outside Laboratory Billing ProtocolSubrogationSurgery InformationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- ForwardHealth
- Fraud, Waste and Abuse
- HealthCheck
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Provider Directory
- Provider resources for Program Integrity Training
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Rights and Responsibilities
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Access StandardsDHS Subcontract requirementsImproper billing of Medicaid Managed Care membersMedical PoliciesPrimary Care - Specialty Care Provider RoleProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider Response Requirements for Member ComplaintsProvider System Outages and or Material BreachProviders' Expectations of Security Health PlanSecurity Health Plans Expectations of Providers
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Utilization Management
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Continuity and Care CoordinationeviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHome HealthHospital admissions - Pre-certificationHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNavihealth-Skilled Nursing Facility CareNorthwood DMENursing Facility Care/Skilled Nursing Facility CarePhysical, Speech and Occupational Therapy - OutpatientPre-certification Notification and Concurrent Review GuidePrior authorizationPrior Authorization for Non-affiliated ProvidersProvider Appeal and Grievance PolicySecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSleep managementSterilization: Hysterectomy CoverageTechnology AssessmentUtilization management general informationUtilization management for behavior healthUtilization management for timeliness standards
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Family Health Center
- Program Overview
- Benefit Information
- Care Management
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Claims Processing and Policies and Procedures
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Anatomical Modifier Requirement PolicyClaims Coding ResourceClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessLimitation of LiabilityModifier InformationNational Drug Code RequirementsOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference Outside Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Pharmacy
- Rights and Responsibilities
- Utilization Management
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Group & Direct Pay
- Product Overview
- Benefit Information
- Care Management
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingNon-covered Services and Experimental/InvestigativeOffice Infusion ProtocolOutput ReportsPrior Authorization Required for Office Based Procedures in ASC or Hospital Outpatient SettingProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- HCC - Risk Adjustment/Government Programs
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
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Pharmacy
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Claims ProcessingDrug FormularyFormulary Exception RequestsGeneral ExclusionsGeneric SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Over-the-Counter Medication CoveragePharmacy Utilization ManagementPrior AuthorizationSpecialty pharmacyStep TherapyTobacco Cessation Coverage
- Provider Directory
- Rights and Responsibilities
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Utilization Management
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Continuity and Care CoordinationDurable Medical Equipment and Home Respiratory EquipmenteviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome HealthHome IV Drug TherapiesHospice ProtocolsHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNorthwood DMEOutpatient Therapy Treatment ConcurrentPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider appeal and grievance policyRadiation Oncology ServicesSecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization management general informationUtilization management for Behavior HealthUtilization management for Timeliness Standards
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Medicare Advantage
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Product Overview D-SNP
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Ally Rx D-SNP BasicsAlly Rx D-SNP Model of CareBilling Ally Rx D-SNP MembersDiscussion of Disenrollment from Medicare AdvantageEncounter Data PolicyMedicare Advantage Part D Data SubmissionsMedicare Advantage Part D Reporting RequirementsMedicare Advantage Reporting RequirementsRecipient of Federal Funds PolicyWhat are Medicare Advantage Plans
- Product Overview HMO and D-SNP
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Benefit Information
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Acupuncture for chronic low back painContinuity and Coordination of CareDental BenefitsEmergency and Non-emergency TransportationEmergency and Urgently Needed Care CoverageHearing Services and Hearing AidsHome Health Care ServicesHome INR MonitoringMacular Degeneration Eye InjectionsPlan OverviewsPreventive Care CoverageRenal DialysisSkilled Nursing FacilityVision and Hardware Coverage
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Care Management
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Additional ProgramsAdvance Directive PolicyChronic Care ManagementCoverage DeterminationEnd Stage Renal Disease (ESRD) Care CoordinationHealth Risk AssessmentHospice Care CoordinationNational Committee for Quality AssuranceNotice of Medicare NoncoverageOutpatient Observation Frequently Asked QuestionsPreventive Service GuidelinesPrograms for MembersQuality Improvement/Utilization Management Program OverviewSecurity Health Plan ProtocolsTwo Midnight RuleWellness and Health Promotion
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyBilling and ReportingClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementRate Letters from CMS for CAH, RHC & Swing BedsReference (Outside) Laboratory Billing ProtocolReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- HCC - Risk Adjustment
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Pharmacy
- Primary Care Provider
- Provider Directory
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Rights and Responsibilities
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Access StandardsMedical policiesProhibition of Interference with Health Care Professionals Advice to Medicare Advantage MembersProvider ContractingProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider Response Requirements for Member ComplaintsProvider System Outages and or Material BreachProviders' Expectations of Security Health PlanSecurity Health Plan's Expectations of ProvidersSkilled Nursing Facility Denial of Medicare/Medicaid Payment
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Utilization Management
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Authorization of Inpatient CareContinuity and Care CoordinationeviCoreHigh End Imaging - Cardiac imaging and elective heart catheterizationHigh End Imaging - Radiation ServicesHome HealthHome IV Drug TherapiesHospice ProtocolsHospital Inpatient Utilization ReviewHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNavihealth-Skilled Nursing Facility CareNorthwood DMEPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider appeal and grievance policyRadiation Oncology ServicesSecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization management general informationUtilization Management for behavior healthUtilization Management for timeliness standards
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Product Overview D-SNP
Ulcers and Wounds
Last Updated on October 06, 2026
Ulcers, wounds and Hierarchical Category Condition Coding
Ulcers are associated with Hierarchical Category Condition Coding (HCC) while wounds are not. Please note that these two conditions are not synonymous.
- Wounds are due to trauma or surgery.
- Ulcers are caused by skin break down from pressure or other chronic conditions.
When known, it is important to document and code the condition that is causing an ulcer. Peripheral vascular disease (PVD), sometimes caused by diabetes or arteriosclerosis may be a cause of skin ulcer. It is important to be as specific as possible in documentation and coding to assure diagnostic accuracy and HCC coding.
Wounds - documentation for wounds should include the following:
- Location
- Complications if present
Ulcers - documentation for ulcers should include the following:
- Location
- Type of ulcer
- Chronic or non-pressure
- Pressure/Decubitus (include stage)
- Stage I - Pressure pre-ulcer skin changes limited to persistent focal erythema
- Stage II - Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis
- Stage III - Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue
- Stage IV - Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon, or bone
- Unstageable – ulcer covered by eschar or that has been treated with skin or other graft, or is documented as a deep tissue injury, but not due to trauma
Additional considerations - please document and code the following details when present:
- Gangrene
- Rest pain
- Intermittent claudication
- Cellulitis - Documentation should include location and organism
- Amputation – Identify the specific extremity and level of amputation
Questions
Brenda Anderson
Revenue Management Educator
Security Health Plan
Telephone: 1-715-221-9598
Email:rf.shp.risk.adjustmnt-mfld@Sanfordhealth.org