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Provider Manual

Utilization Management General Information

Last Updated on October 02, 2019

People often have misconceptions about utilization management programs. At Security Health Plan all of our decisions are based on making sure our members have the appropriate care and services. Our utilization management professionals have no financial incentives to deny services. Our UM decision-making is based only on appropriateness of care and service and existence of coverage. We work with our affiliated providers to elevate and improve delivery of health care and to improve outcomes. Our philosophy is to provide the appropriate care at the appropriate time in the appropriate setting for the appropriate length of time. Key components of the Utilization Management program followed for our members are described below:

  • Pre-Certification Notification and Concurrent Review Guide
  • Prior Authorization and Precertification
  • Behavioral Health Admissions
  • Shared decision-making:
    • Shared decision-making as part of the prior authorization process is required ONLY for State of Wisconsin Employee Trust Fund (ETF) members for certain surgical procedures. Please refer the member to their certificate or call Security Health Plan. At this time, ETF members are required to complete the shared decision-making process prior to receiving the following surgeries.
        • Carpal Tunnel - Median Neuropathy - Specialty Consult
        • Chronic Hip Pain - Osteoarthritis - Specialty Consult 
        • Chronic Knee Pain - Osteoarthritis or Meniscal Degeneration - Specialty Consult 
        • Hysterectomy with fibroid diagnosis
        • Low Back Pain - Orthopedic or Neurosurgery Consult
  • Continuity and Care coordination of care
    • Security Health Plan believes its members should receive seamless, continuous, and appropriate care through communication between behavioral health providers and primary care providers. The Health Insurance Portability & Accountability Act (HIPAA) privacy regulations supports Security Health Plan’s interest in patient safety and coordination of care.
    • When patients present for behavioral health care, they need to be informed about how their records will be handled and, in certain circumstances, to give consent or authorization regarding what information can be shared and with whom. Coordination of care reduces the risk of problems when patients see multiple providers in different settings and when providers lack access to the patient’s complete medical record. Important mental health information to be shared would include patient diagnosis, medication(s) and/or treatment plan.
    • In Security Health Plan’s effort to provide high-quality health care, Security Health Plan requires affiliated behavioral health providers to communicate with primary care providers. Security Health Plan monitors this activity through an annual provider survey sent to both behavioral health providers and primary care providers. Providers indicate if they believe it is important to share this information as well as if the sharing of this information occurs.
    • Security Health Plan appreciates providers’ help and cooperation in this matter to improve communication between providers through continuity and coordination of care.
  • Attestation of noncompensation
    • Security Health Plan utilization management (UM) decisions are based on nationally recognized and accepted clinical criteria and internal policy for determining appropriateness of care and availability of coverage.
    • Security Health Plan does not specifically reward providers or other individuals for issuing denials of coverage, nor does Security Health Plan make decisions regarding hiring, promoting or terminating individuals in UM decision-making based upon the likelihood or perceived likelihood that the individual will support or tend to suppor the denial of benefits.
    • Security Health Plan does not have financial incentives in place for UM decision makers; therefore, UM decision makers are not encouraged to make decisions that result in underutilization.
  • How to access the medical director
    • Affiliated providers may discuss a utilization management decision with the Security Health Plan medical director by calling 715-221-9640 or 1-800-548-1224.
  • How to access utilization management criteria
    • Physicians and nurses at Security Health Plan use clinical criteria to make coverage decisions based on medical necessity. Nationally recognized guidelines that are modified with identification of those services available within the Security Health Plan network are used to make consistent decisions. Some examples of these guidelines are Hayes Medical Technology, Mckesson InterQual Level of Care Criteria, American Society of Addiction Medicine, Wisconsin Uniform Placement Criteria, and Mckesson. InterQual Level of Care Criteria are used to evaluate admission into inpatient and transitional services as well as for concurrent review. Hayes Medical Technology is used to identify those services that are considered to be experimental or investigational.
    • If seeing a Security Health Plan member and there are questions regarding the Mckesson InterQual criteria used to make a determination of coverage, call Security Health Plan and receive a copy of the criteria at 1-800-548-1224, ext. 19640.
  • Technology Assessment
    • Formal review process of new medical technology and new applications of existing medical technology to ensure that members have equitable access to safe and effective care.
Security Health Plan will make a final claim decision after we review the claim, verify eligibility, and determine whether the service performed is a covered benefit under the policy.