Provider Manual
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Medicaid Managed Care
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Benefit Information
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Care Management
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Claims Processing Policies and Procedures
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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
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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
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Group & Direct Pay
- Product Overview
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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
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Pharmacy
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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
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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
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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
Musculoskeletal procedures
Last Updated on February 19, 2026
eviCore healthcare is contracted by Security Health Plan to provide prior authorization (PA) review of certain musculoskeletal services.
These authorizations are for members enrolled in Security Health Plan employer, individual or family, BadgerCare, Medicare Advantage plans and Insite by Security Health Plan plans. For Insite groups please review each member ID card to find the utilization management vendor (e.g. Hines) and prior authorization requirements.
It is the rendering provider’s responsibility to ensure prior authorization requirements are met before a member’s scheduled appointment. If PA requirements are not met, claims could be denied. If a provider changes any of the prior authorized service(s) during surgery to perform services other than the ones for which PA was obtained, the provider must contact Security Health Plan within 72 business hours of the procedure to provide the new CPT code(s) that were performed. The provider must notify eviCore at 1-888-444-6185 with the updated information. If the provider does not notify eviCore of the changes within 72 business hours of procedure, the claims for the unauthorized codes will be denied.
Rendering providers should contact eviCore to obtain PA for members per the guidelines outlined above and in the provider training materials.
Therapy services performed in conjunction with an inpatient stay, 24-hour observation or emergency room visit are not subject to prior authorization requirements.
Authorization is required for:
- Joint surgeries
- Spine surgeries
- Interventional pain management
Request Authorization
To request a prior authorization:
- Log in to www.evicore.com/pages/ProviderLogin.aspx
- Call eviCore at 1-888-444-6185
- Fax an eviCore healthcare request form (available at www.evicore.com) to 1-885-511-0403
For urgent requests:
If services are required in less than 48 hours due to the severity of the clinical presentation, please call eviCore’s toll-free number or you can initiate a case via the eviCore web portal for expedited prior authorization review. Be sure to tell the eviCore representative that the prior authorization request is for an urgent clinical presentation. If initiating the urgent request via the web you will have to upload clinical documentation with the case initiation. To request an authorization, submit your request online, by phone or fax.
Resources
View code list for the following prior authorizations:
- Joint surgeries
- Back surgeries
- Interventional pain management
- Musculoskeletal management quick reference guide
- eviCore musculoskeletal program FAQ
eviCore healthcare’s Clinical Guidelines and request forms are available at: www.evicore.com or click here to access guidelines specific to Security Health Plan. Please call the Client Provider Operations Department at 1-800-646-0418, option 4, if you have any questions or need more information.