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Provider Manual

New prior authorization and shared decision-making requirements apply to orthopedic surgeons and neurosurgeons

Last Updated on August 28, 2018

Effective December 1, 2016, shared decision-making as part of the prior authorization process is required ONLY for State of Wisconsin Employee Trust Fund (ETF) members.

Prior notification and completion of the shared decision-making (SDM) tool is required for referrals from a primary care provider to an orthopedic surgeon, neurosurgeon, general surgeon or plastic hand surgeon for any office visit or consultation, and/or surgery for the following conditions:

As of April 1, 2016, if prior notification is not obtained for an orthopedic surgeon, neurosurgeon, plastic hand surgeon or general surgeon consultation with a member, reimbursement/payment for the appointment and any related services/procedures will be denied. The denied claim will be the responsibility of the provider and facility.

For low back pain consults only: If the member had back surgery in the past year and was insured by Security Health Plan at the time of the surgery, how long can the member see a provider for follow-up consults before a new prior authorization is required?
If the member was insured by Security Health Plan at the time of the surgery for low back pain and the member has had surgery one year or less from the date of consultation, no prior authorization is required.

For example, if a member had surgery on September 1, no prior authorization is required for a consultation that occurs prior to August 31 of the next year.

What is the definition of “current” or “active” course of treatment?

Current or active course of treatment is a planned treatment program occurring now or within the last six weeks of the initial consult request.

If a patient chooses to go directly to the specialist for a consult, can the specialist make the call to the primary care provider requesting the prior authorization?
The specialist office may call the primary care provider (PCP) indicating a prior authorization from the PCP office is required for a consult, but the member must still meet the requirements of the prior authorization and complete the shared decision-making tool before going to the specialist consult visit.

Effective December 1, 2016, shared decision-making as part of the prior authorization process is required ONLY for State of Wisconsin Employee Trust Fund (ETF) members.
If Security Health Plan is the secondary coverage for a member, is a prior authorization for a consult required?
If Security Health Plan is secondary, prior authorization for a consult is not required at this time and neither is completion of the shared decision-making tool.
Does the prior authorization requirement for a consult apply to emergency departments?
The prior authorization requirement does not apply to care provided in the emergency department, inpatient setting or observation setting when professional services are billed with the appropriate site of service codes.
Does the prior authorization requirement for a consult apply to all ages?
The prior authorization requirement applies to members 18 years and older.
Does the shared decision-making requirement apply to all members with primary coverage through Security Health Plan?
Effective December 1, 2016, shared decision-making as part of the prior authorization process is required ONLY for State of Wisconsin Employee Trust Fund (ETF) members.
How long does it take for shared decision-making to be completed?

Security Health Plan’s shared decision-making team will contact the State of Wisconsin Employee Trust Fund (ETF) member. The ETF member can complete the shared decision-making tool by phone or email link.  If the member chooses to receive the tool by email link, they have up to 2 days to complete the tool.

If the member does not complete the shared decision-making tool, Security Health Plan will not grant prior authorization. If a provider or member proceeds with a procedure without prior authorization, all professional and facility claims will be denied to the provider and facility responsible.

Where are the prior authorization forms located to initiate a review?
Click here for a complete and up-to-date list of prior authorization forms.


Last updated: 7/1/2017