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Provider Manual

Pre-certification of Hospital Admissions

Last Updated on July 01, 2022

The provider, not the member, is responsible to precertify an admission to the hospital for medical and/ or surgical treatment.

  • Notify Security Health Plan at 1-800-548-1224 of all acute inpatient admissions within 48 hours of admission.
  • Fax the appropriate clinical information within 24 hours of notification of observation admission to Security Health Plan Health Services at 715-221-9980. If the provider fails to provide the needed clinical information within 24 hours of the notification of admission (Observation and/or Inpatient), Security Health Plan will deny for provider contract requirement. Each day will be denied to the provider until Security Health Plan receives required clinical information. Provider cannot bill the member for these denied charges.

Based on medical diagnosis or proposed surgery and medical information, Security Health Plan will:

  • authorize coverage for a length of stay is based on InterQual Level of Care Guidelines. (Remember that these are a minimum length of stay consistent with quality care. Actual length of coverage for a stay is based on medical necessity and intensity of service)
  • If ultimately it is determined that the patient did not meet medical necessity for the admission, payment for services will be denied to the Provider .Provider cannot bill the member for these denied charges. Provider may appeal through Security Health Plan’s Appeal Process. The appeal process can be found here.
  •  upon request, send a copy of the appropriate guidelines (available by contacting the Security Health Plan utilization management specialist).

Contact the Security Health Plan utilization review coordinator at 1-800-991-8109 (option #1 or #2) or 715-221-9768 or 715-221-9661.

Hospital responsibilities include:

  • Notify Security Health Plan at 1-800-548-1224 within 48 hours of all observation with length stay greater than 48 hours and acute inpatient admissions. Provide clinical information within 24 hours of notification or the next business day.
  • Provide timely concurrent review activities (telephonic and on-site) to prevent penalty for late notification. A timely review is defined as providing clinical information within 24 hours of the last covered day
  • Failure to provide this information means Security Health Plan will not be able to perform timely initial or concurrent review of the admission. Security Health Plan will therefore not reimburse the facility for covered services incurred prior to the performance of the initial or concurrent review of the admission. The facility shall not bill, charge, collect a deposit from, seek remuneration or compensation from the Security Health Plan member, or any person acting on the member’s behalf, for covered services incurred prior to the performance of the initial or concurrent review.