Provider
News
September 2019
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Security Health Plan now distributes
Provider News
digitally. Information in this newsletter is important for care providers, clinic managers, patient assistance, coding and other clinic staff. Please share with your colleagues.
If you wish to receive this bi-monthly newsletter, please create a Provider Portal account by contacting your practice's organization administrator. If you don't have an organization administrator,
click here
to set one up.
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Neillsville woman credits Security Health Plan as her 'lifeline' after her husband suffers two strokes
Reassurance from a Security Health Plan registered nurse care manager put a plan member at ease when she was at her most vulnerable.
Read more
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Security Health Plan's most prevalent Hierarchical Condition Category codes and associated diagnoses
By BRENDA ANDERSON, Revenue Management Educator
Risk adjustment revenue is based upon member demographics and diagnostic conditions. Diagnostic conditions are determined from provider coding on claims for service. These conditions are often referred to as Hierarchical Condition Category or HCC codes.
Risk adjustment programs are important to Security Health Plan and its members for multiple reasons.
Read more
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Security Health Plan policy review - July and August 2019
Security Health Plan reviews medical policies on a monthly basis. Medical policies are found in the provider section of the Plan's public website. As we review and develop clinical criteria for our policies, providers with particular professional knowledge or clinical expertise on certain subjects are invited to provide input and opinions.
Read more for
July and August 2019 policy reviews and changes.
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Provider expertise requested for medical policies and criteria
As Security Health Plan reviews and develops clinical criteria on Medical and Interpretation Policies, we ask providers with particular professional knowledge or clinical expertise on certain subjects for their input and opinions.
To receive payment, providers must meet all policy criteria outlined for the specific service provided.
Please review the current month’s medical policy updates and/or changes at
www.securityhealth.org/medicalpolicies.
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Security Health Plan updates
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Security Health Plan upgrades provider portal with TruCare ProAuth feature
By THERESA STERNIK, Health Services Clinical Manager
Security Health Plan has upgraded its Population Health Platform, which went live on Sept. 19, 2019. Part of this process included an addition of the TruCare ProAuth feature. TruCare ProAuth is a web portal application that allows providers to submit inpatient and service/procedure authorization requests. These requests will include both medical and behavioral health conditions. The authorization request can be submitted and have clinical review validation with IQ Connect.
Read more
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Telehealth service coverage expands in 2020 for Medicare Advantage plans
By JENNIFER DENNEE,
Government Policy and Reimbursement Specialist
Effective January 1, 2020, the Centers for Medicare & Medicaid Services (CMS) is eliminating
standard fee-for-service restrictions on telehealth access for Medicare Advantage plans (not including our Secure Saver MSA plan). In an effort to increase virtual care choices and benefits, Security Health Plan Medicare Advantage members will have additional telehealth and virtual care benefits beyond Original Medicare. This includes greater access to telehealth services in both rural and urban areas, even in their own home.
Read more
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Patient-Driven Payment Model replaces RUGs for Medicare Part A payment to skilled nursing facilities
By DAVID NYMAN, Director, Payor Strategy and Network Contracting
Effective Oct. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) will be implementing a new Skilled Nursing Patient-Driven Payment Model (PDPM). PDPM is a fundamental shift from RUGs IV and will replace RUGs entirely for Medicare Part A payment to skilled nursing facilities (SNFs). This serves as a notice that Security Health Plan will be implementing the new payment model to stay compliant with contractual language and CMS reimbursement requirements.
Read more
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Partnership with home infusion providers brings convenient, cost-effective care to members' homes
By TRACY LAPOINTE,
Health Services Clinical Manager
Security Health Plan is making it easier for members to receive injectable medications at home by partnering with several home infusion providers. Whenever clinically appropriate, members have the opportunity to receive intravenous (IV), subcutaneous (SQ), or intramuscular (IM) drugs in the comfort of their home and avoid frequent trips to the hospital or clinic.
Read more
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Security Health Plan adds coverage for 3D mammography
Breast cancer is the most common cancer among women, and having early detection and saving lives is the goal of Security Health Plan. Security Health Plan will cover digital breast tomosynthesis (DBT), commonly known as 3D mammography,
in conjunction with 2D imaging
, for screening or diagnostic purposes for all programs except BadgerCare. Previously, 3D mammography services were denied as experimental/investigational.
Digital breast tomosynthesis provides the best chance to catch breast cancer at its earliest stage when treatment is most effective.
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Medicare Part B step therapy program adds additional
in-scope indications for certain previously targeted drugs
By KURT WITTIG, Clinical Pharmacy Specialist
The Centers for Medicare and Medicaid Services previously issued guidance that provies Medicare Advantage plans the option of applying step therapy for physician-administered Part B drugs in a way that lowers costs and improves the quality of care for Medicare beneficiaries.
Read more
on additional in-scope indications for certain previously targeted drugs.
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Xeomin
(R)
is preferred botulinum toxin
Effective for dates of service on or after Jan. 1, 2020, Xeomin
®
(botulinum A toxin) will be the preferred botulinum product for the indications which overlap with the following:
- Botox® (botulinum A toxin)
- Dysport® (botulinum A toxin)
- Myobloc® (botulinum B toxin)
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Security Health Plan discontinues participation in State of Wisconsin health insurance program
Security Health Plan has made the difficult decision to discontinue our participation in the health insurance program for the State of Wisconsin’s Employee Trust Fund (ETF), which provides coverage for State of Wisconsin employees. This decision, effective January 1, 2020, was made after weighing all the pros and cons.
Read more
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Use Provider Portal to verify claims information
Claim status, eligibility, benefits and prior authorization requirements can be verified on the Security Health Plan Provider Portal.
Click here
for information on Provider Portal access and other ways to get the information you need by email, phone and fax.
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Portal access should be shared only within practice
By RHONDA LOKKEN, Provider Relations Account Manager
Security Health Plan providers are reminded that when requesting access to Security Health Plan’s Provider Portal, they agree to grant access only to users within the same practice/organization. Providers are not allowed to share usernames and passwords with each other or with third parties. However, providers may set up access (usernames) for third party users when the third party is contracted with their organization specifically for billing purposes.
Use the Provider Access Request form
linked here, which can also be
found on the Provider Portal to request access for users in your practice.
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Security Health Plan partners with LexisNexis Risk Solutions and AMA Business Solutions to verify provider information
By DAVID NYMAN, Director, Payor Strategy and Network Contracting
As you know, it is vital that your patients have access to accurate,
up-to-date information about their providers in the Security Health Plan Provider Directory. Security Health Plan is required to attest to the accuracy of its provider network information to various state and federal entities. Additionally, CMS requires that providers review and update their information quarterly or whenever there is a significant change. To help you meet this requirement, Security Health Plan has engaged with the search firm LexisNexis Risk Solutions and the American Medical Association’s AMA Business Solutions.
Read more
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Security Health Plan uses InterQual 2019 guidelines
Security Health Plan is using the 2019 InterQual Criteria for medical necessity reviews of elective or urgent admissions for dates of service Aug. 1, 2019, and forward.
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Prior authorization updates
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Clarifying eviCore healthcare occupational, physical and speech therapy prior authorizations
By THERESA STERNIK, Health Services Clinical Manager
Security Health Plan and eviCore healthcare have been in partnership to provide authorization services for patients enrolled in Security Health Plan’s Commercial, BadgerCare Plus, Medicare Advantage and Security Administrative Services plans. Security Health Plan members in the above plans have required prior authorization from eviCore healthcare for occupational therapy, physical therapy and speech therapy for dates of service beginning May 1, 2019. Security Health Plan would like to provide clarification with therapy prior authorization.
Read more
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January 2020 updates to medication prior authorizations and post service claim edits
By AMANDA SIEGLER,
Clinical Pharmacy Specialist
Security Health Plan (SHP) requires prior authorization (PA) or post service claim edits (PSCE) for certain medications in order to ensure coverage and payment for those services.
Read more about new requirements effective on Jan. 1, 2020.
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Peer-to-peer re-review process available for specialty pharmacy medication denials
A peer-to-peer or re-review process is the requesting provider’s opportunity to provide additional information on their patient case directly to a pharmacist or physician. This allows the provider to explain in detail as to why it is medically necessary that a patient is a candidate for a medication even if not meeting all of Security Health Plan’s or Magellan’s policy criteria.
Read more
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Help patients find you
- Has your practice moved?
- Have you changed the name or ownership of your practice?
- Do all of your providers accept new patients?
- Is anyone seeing patients in a new or different location?
- Has anyone left your practice or been replaced in the last year?
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Help patients find you by keeping information about your practice current with Security Health Plan.
Security Health Plan’s online provider directory is the primary provider search tool we offer our members. Members use the “Find a Doctor” directory to search for providers who can fill their specific care needs, whether they’re looking for a primary care provider who sees children, a specialist with privileges at a specific hospital, or an affiliated nursing home near their aging parents.
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To help patients find you, visit
www.securityhealth.org/directory
. Whether you’re a provider, a practice or a facility, please review the directory information for accuracy.
Be sure to contact us right away with any needed updates: You can report a change to Provider Relations staff. Call us at
715-221-9640
(TTY: 711), fax changes to us at
715-221-9699
or email us at
[email protected]
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