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Provider Manual

Prior authorization (PA) / Notification requirements

Last Updated on August 28, 2018
 
Name Medicare Advantage
BadgerCare Commercial Family Health Center
Shared Decision Making Required How to request PA or Provide Notification Details
72-hour Continuous Glucose Monitoring x x x x
  Prior Authorization form  
Abdominoplasty x x x   Prior Authorization form

Medicare Advantage Coverage Inquiry
x        
Medicare Advantage Coverage Inquiry Form

Air ambulance transport x x x     Call Security Health Plan at 1-800-991-8109  
Amino Acid Formula   x x     Prior Authorization form
Antibiotic - Antiviral Intravenous Infusion x x x     Prior Authorization form
Autologous Cultured Chondrocytes x x x x
  Prior Authorization form
Breast Reconstruction
x
x
x
x
  Prior Authorization form
 
Durable Medical Equipment, Prosthetic, Orthotic Suppliers
Effective July 1, 2015, Security Health Plan is partnering with Northwood, Inc. (Northwood) to manage DMEPOS services 
x x x     •Log into www.northwoodinc.com/security-health-plan/
•Phone at 866-532-1344
•Fax 866-483-9988
•Provider Portal for entities contracted with Northwood: https://providerportal.northwoodinc.com

Carpal tunnel
x
x
x
 
Prior Authorization form
 
Carpal tunnel – Median Neuropathy – Specialty Consult x x x   x Prior Authorization form Details
Chronic Hip Pain – Osteoarthritis – Specialty Consult x x x   x Prior Authorization form Details
Chronic Knee Pain - Osteoarthritis or Meniscal Degeneration – Specialty Consult x x x   x Prior Authorization form Details
Clinical trials x   x     Call Security Health Plan at 1-800-991-8109  
Cosmetic/reconstructive surgery x x x x
x
Call Security Health Plan at 1-800-991-8109  
Elective inpatient admission including medical, surgical and behavioral health x x x     Call Security Health Plan at 1-800-991-8109  
Electrical Stimulation and Electromagnetic Therapy - Service x x x x
x
Prior Authorization form
Experimental or investigational services x x x x
x
Call Security Health Plan at 1-800-991-8109  
Fecal Transplant
    x
    Call Security Health Plan at 1-800-991-8109   
Genetic Testing (Effective January 1, 2017)
x
x
x
x
  Prior Authorization form
 
High-end Imaging Services
 - CT scan
 - Low DoseCT for Lung Cancer Screening
 - MRI
 - MRA
 - CTA
 - PET
x x x     •Log into www.medsolutionsonline.com
•Phone at 1-888-693-3211
•Fax a eviCore request form (available online) to 1-888-693-3210
 
Home Health Prior Authorization Form x x x     Prior Authorization form
Home Infusion-Chemotherapy x x x x
  Prior Authorization form Details
Hospice     x     Call Security Health Plan at 1-800-991-8109 Details
Hospital Admission - precertification x x x     Call Security Health Plan at 1-800-991-8109 Details
Hospital Observation Admission
x
x x
    Call Security Health Plan at 1-800-991-8109 
Hysterectomies for diagnosis of fibroids (elective)     x   x Call Security Health Plan at 1-800-991-8109 Details
Infuse Bone Graft x x x     Prior Authorization form  
Inpatient Admissions/Surgeries x x x     Call Security Health Plan at 1-800-991-8109 Details
Inpatient Procedures performed in ASC x x x     Call Security Health Plan at 1-800-991-8109  
Intrastromal Corneal Ring Segments x   x     Prior Authorization form  
Intravenous Immunoglobulin - Subcutaneous Immunoglobulin Infusion x x x     Prior Authorization form
IV Infusion Therapy Authorization Request x x x x
  Prior Authorization form
Knee Arthroscopy
x
x
x
 
Prior Authorization form
 
Lipectomy x x       Prior Authorization form
Low Back Pain – Orthopedic or Neurosurgery Consult x x x   x Prior Authorization form Details
Lung Volume Reduction Surgery x x x     Prior Authorization form
Nonaffiliated Providers Request x x x     Prior Authorization form Details
Non-emergent ambulance transport x x x     Call Security Health Plan at 1-800-991-8109  
Office procedure with site of service request other than in office setting

x     Call Security Health Plan at 1-800-991-8109  
Outpatient procedure with site of service request as inpatient setting x x x     Call Security Health Plan at 1-800-991-8109  
Outpatient Therapy Treatment (Concurrent) x
x
    Prior Authorization form Physical, Speech and Occupational Therapy - Outpatient
Therapy Guidelines
Outpatient Therapy Treatment (Initial) x
x
    Prior Authorization form
Panniculectomy x x x x
  Prior Authorization form
Parenteral Nutrition Home Infusion x x x x
  Prior Authorization form
Port Wine Stain - Abnormal Vascular Lesion Treatment x x x x
  Prior Authorization form
Radiation Oncology Services
x
x
x
    •Log into www.carecorenational.com
•Phone at 1-888-444-6185
Details
Reduction Mammoplasty x x x x
  Prior Authorization form
Rhinoplasty x x x x
  Prior Authorization form
Second Opinion   x x     Call Security Health Plan at 1-800-991-8109 Details
Septoplasty x x x
x
  Prior Authorization form
Skilled Nursing Services
 - Acute rehabilitation admission
 - LTAC admission
 - Skilled nursing facility admission
x   x     naviHealth at (Phone) 855-512-7002 or
naviHealth  (Fax) 855-847-7243
Details
Spinal Cord Stimulator x x x     Prior Authorization form
Surgical Treatment for Obesity x x x x
  Prior Authorization form
Swing bed admission x   x     Call Security Health Plan at 1-800-991-8109  
Synagis   x x     Prior Authorization form
Total Hip Replacement
x
x
x

 
Prior Authorization form  
Total Knee Replacement
x
x
x


Prior Authorization form
 
Transgender services (Effective January 1, 2017)
x
x
x
    Prior Authorization form   
Transplants x x x     Call Security Health Plan at 1-800-991-8109  
Wearable Hearing Aids
    x (Large Group only)
    Prior Authorization form

Please call 1-800-548-1224 to find out if this prior authorization applies to your patient.