Effective January 1, 2015 the standard elective surgical precertification process as well as completion of the shared decision-making tool is required for all elective hysterectomies for a diagnosis of fibroids.
If no precertification is obtained and shared decision-making is not completed, professional and facility reimbursement/payment for the surgery and any related services/procedures will be denied. Claims will be denied as provider responsibility.
Q & A about elective hysterectomies for fibroid diagnosis
To which members and insurance products does this requirement apply?
This requirement applies to State of Wisconsin Employee Trust Fund members.
Prior authorization for Security Administrative Services is required for most, but not for all members of self-funded groups. If prior authorization is done by a company other than SAS, the contact information will appear on the back of the member’s ID card.
Prior authorization for elective surgical hysterectomy procedure does not apply to the Family Health Center and Senior Security members.
What are the prior authorization requirements?
The surgeon would need to notify Security Health Plan of any elective, inpatient surgeries.
Who is responsible to obtain the prior authorization for all elective inpatient and outpatient surgical procedures for hysterectomy with the diagnosis of fibroids?
The surgeon’s office is responsible to obtain the prior authorization for all hysterectomy with diagnosis of fibroids.
If prior authorization is not obtained how are claims affected?
If no prior authorization is obtained and/or the member does not complete the shared decision-making tool, professional and facility reimbursement/payment for the surgery and any related services/procedures will be denied. Claims will be denied as provider responsibility, to both the provider and the facility.
What is the shared decision-making tool?
The shared decision-making tool use evidence-based clinical criteria that will provide members with the education and information they need to make an informed decision about the surgical care they are seeking. The provider must obtain prior authorization and the member must complete the shared decision-making tool for hysterectomy with diagnosis of fibroids.
How will the member complete the shared-decision making tool?
Security Health Plan members will complete the shared decision-making tool by the Internet or telephonically with the assistance of a Security Health Plan care manager.
How will the surgeon be notified that shared decision making has been completed by the member?
Security Health Plan will notify the surgeon by telephone once shared-decision making and final determination is completed, or the surgeon can obtain the information from Security Health Plan by calling 1-800-548-1224.
What is the time frame within which Security Health Plan will honor a member’s shared decision-making process for a given surgery?
Once the member completes the shared decision-making tool, and Security Health Plan notifies the provider and member of the authorization, the authorization is good for 60 days.
Does this requirement apply to just new patients OR to new and existing patients?
The prior authorization requirement iseffective for all dates of service as of January 1, 2015.
If Security Health Plan is the secondary coverage for a member, is a prior authorization required?
If Security Health Plan is secondary, prior authorization and shared-decision making is required.
Does the prior authorization requirement for hysterectomy apply to emergency departments?
No. The prior authorization and shared-decision making tool requirements are for elective hysterectomies with a diagnosis of fibroids.
Does the prior authorization requirement for hysterectomy apply to all ages?
The prior authorization requirement for hysterectomy applies to members 18 years and older.
What is Security Health Plan’s timeliness requirement to complete prior authorization for elective hysterectomy?
Security Health Plan has 14 calendar days from the date of receipt of elective/non-urgent prior authorization requests (via telephone or provider portal) to make a determination.