Provider News

May 2025

Use Security Health Plan's Provider Portal to verify claims and medical and/or pharmacy prior authorizations

You can check claim status, eligibility, benefits, prior authorization requirements and verify other information on the Security Health Plan Provider Portal at www.securityhealth.org/providers. If you would like more information on how to access the Provider Portal and other Provider Portal resources, click here.

Security Health Plan updates

Survey to close on Saturday, May 31.

Medicaid Behavioral Health Survey

As part of a requirement from the Wisconsin Department of Health Services (DHS), Security Health Plan must ensure that age-appropriate behavioral health screening and assessment tools are used for Medicaid patients aged 18 and under in primary care settings.

To meet this requirement, we are asking Medicaid-licensed Med-Peds, Pediatric and Family Medicine providers to complete this short ten-question survey.

Take the survey

Claims, coding and prior authorizations

Provider rights and responsibilities - appeals

Effective May 1, 2025, for Medicare Advantage products, providers must appeal within 65 days of the provider statement on which the charge was denied or partial payment of claims was made. All claims processed on or after May 1, 2025, will follow the 65-day appeal timeframe and any claims processed before May 1, 2025, will follow the current 365-day timeframe. There are no changes to commercial or Medicaid products; commercial will remain at 365 days and Medicaid at 60 days.

Security Health Plan’s full provider appeal policy can be found at www.securityhealth.org/providerappeal

Pharmacy

Important information regarding Humira® and Stelara® Biosimilar Strategy

By Amanda Siegler, PharmD

Clinical Pharmacy Specialist

As part of our commitment to stewardship and delivery of quality care, Security Health Plan will remove Humira® and Stelara® from the formulary effective Tuesday, July 1, 2025, for all Commercial and Marketplace lines of business. Patients will be required to switch to a preferred biosimilar. Read more.

Pharmacy and Therapeutics summary

By Kurt Wittig, PharmD

Clinical Pharmacy Specialist

At Security Health Plan, we want you to know about any changes that may impact Security Health Plan members and providers. Below are the changes approved by the Security Health Plan Pharmacy and Therapeutics Committee from the March 2025 meeting, which include updates to medication prior authorization (PA) criteria and formulary placement for certain medications. Read more.

Helpful links

By Kurt Wittig, PharmD

Clinical Pharmacy Specialist

At Security Health Plan, our goal is to enhance awareness of formulary coverage, prior authorization (PA), and other utilization management (UM) policies related to medications. To support this effort, we are providing relevant hyperlinks. Read more.

Policy review

2025 Change Healthcare InterQual Criteria update

On April 1, 2025, Security Health Plan started using Change Healthcare's 2025 InterQual Clinical Criteria update. InterQual Level of Care Criteria is used to evaluate services for medical necessity, including the following:

Concurrent review
Inpatient procedures
Inpatient urgent admissions
Outpatient procedures
Post-acute services
Transitional services

Security Health Plan April 2025 policy updates

By Karen Borgemoen, RN

Nurse Navigator, Medical Policy Nurse, Team Lead

Security Health Plan reviews medical policies monthly. You can find our medical policies in the provider section of Security Health Plan’s public website. Read more.

New update on Medicare coverage of diabetic foot and venous leg ulcers

The Updated Medicare coverage for treatment of diabetic foot and venous leg ulcers that was to take effect on April 13, 2025, has been delayed until January 6, 2026. Security Health Plan will not require prior authorization and will cover all Medicare-approved skin substitutes for Medicare Members. Security Health Plan will cover 10 applications over 12 weeks per wound, regardless of whether the skin substitutes used are all the same or a combination of skin substitutes. These limitations will not apply to members with a breast cancer or burn diagnosis.

Partners in Health

How an adjunctive treatment can give hope to patients with panic attacks and PTSD symptoms

Freespira is an adjunctive treatment for patients with PTSD or panic disorder symptoms that is clinically effective when used alone or alongside other treatment methods, such as psychotherapy or medication use. Because Freespira does not involve the use of medication, there is no risk of drug interactions with the treatment. Read more.

Reminders

All providers are legally required to report suspected child abuse

All providers are legally required to report suspected child abuse and neglect. They must also understand how to report, as well as the laws, identification requirements and reporting procedures involved.

Quest Analytics' Better Doctor to verify provider directory information

To ensure health plan members have access to accurate, up-to-date provider directory information, Security Health Plan partners with Quest Analytics’ BetterDoctor to collect quarterly provider data attestations for all contracted providers. Read more.

Hospital access payment reports are available online

View your hospital access payment reports on the Security Health Plan Provider Portal. Payments are distributed monthly to your practice from Security Health Plan and are based on the number of Medicaid-qualifying inpatient discharges and/or outpatient claims from the prior month for an eligible hospital. Security Health Plan encourages electronic payments (or ACH payments) as they are more secure and cost-effective. Read more.

Security Health Plan requires the use of the provider portal to submit prior authorization requests

Submit your prior authorization (PA) electronically through the Security Health Plan secure provider portal and receive decisions more quickly than the traditional method of faxing or calling in a request. Read more.

ProAuth updates make it easier for providers to view TruCare letters

Security Health Plan recently updated its TruCare and ProAuth to version 10.1.1.0.0. With this new upgrade, your practice can view letters that have been generated via Trucare through the ProAuth tool. Read more.

The Centers for Medicare & Medicaid Services (CMS) requires a rate letter for reimbursement of inpatient and outpatient services

Security Health Plan’s reimbursement for critical access hospital, swing bed and rural health clinic’s inpatient and outpatient services is based on their most recent rate letter from CMS. Security Health Plan cannot access facility rate letters and needs to receive them from providers. Read more.

Security Health Plan offers language resource assistance

Security Health Plan providers with patients that require language assistance, the telephone language line is provided free of charge. This line is intended for our contracted providers who do not have access to interpretation services and need to interact with Security Health Plan patients who do not speak English or have limited English language proficiency. Read more.

Provider resources and reminders

Provider feedback and testimonials wanted

Have you had a great experience with Security Health Plan staff that you would like to share? Did they go above and beyond to answer your question, resolve your issue or help your patient get the care they needed? Do you have an idea for a new or enhanced feature for the Security Health Plan Provider Portal or Provider Manual? Are you looking for a better way to access information?

If you answered yes to any of the above, then we would love to hear from you! We want to provide you with the best experience possible and appreciate your input. Click here to submit your feedback. Read more.

Security Health Plan Compliance Toolkit

Click here for details about the FDR Attestation and Security's tools to assist you in meeting your regulatory requirements.

Important online information is a click away

You can find important information on services, standards, processes and clinical practice guidelines when you visit our Provider and Facility Manuals at www.securityhealth.org/providermanual. Read more.

Get monthly pharmacy formulary updates

Security Health Plan updates its interactive formulary to reflect changes before the fifth business day of each month. The Security Health Plan website also contains important information regarding covered medications, tier levels, prior authorization, quantity limits, generic substitution and step therapy. Providers are encouraged to review the Security Health Plan website regularly for the most recent updates. To learn more, visit www.securityhealth.org/prescriptiontools.

Quality matters to us

Thank you for working with us to keep improving our programs and services for our members, your patients. To find out more about our quality improvement efforts, visit www.securityhealth.org/quality.

Hours of availability

Remember, the hours of availability your practice offers to Medicaid patients must be no less than those offered to commercial patients.

Provider phone line available

If you can’t find your answer on the provider portal, Security Health Plan has staff available to take your calls during business hours, Monday through Friday, 8 a.m. to 4:30 p.m. Please call our provider assistance line at 1-800-548-1224 (TTY 711). Click here to read more about our provider assistance line and other provider resources.

Provider credentialing: Your right to review

Any provider has the right to review his or her credentials record in person at the Credentialing Office during normal business hours. The Credentialing Office is located on the ground floor of the Marshfield Clinic campus at 1000 North Oak Avenue, Marshfield, WI 54449. Click here to link to the Provider Credentialing Manual.

Security Health Plan patient coverage review policies

When you and your patients ask Security Health Plan to cover certain medical services, we go through a rigorous review process to ensure our members’ coverage is applied correctly. For more information on our decision-making policies or to receive a copy of the criteria used to make coverage decisions, please call Customer Service at

1-800-472-2363 (TTY 711). Read more.

Your patients’ rights

Patient care involves patient rights and responsibilities. For example, did you know your Security Health Plan patients have the right to know about all treatment choices that are recommended for their condition(s), including the right to request a second opinion, no matter what they cost or whether they are covered by Security Health Plan? And the responsibility to act in a way that supports the care given to other patients and helps ensure the smooth running of their doctor’s office, hospitals and other offices?