ProviderNews. Security Health Plan approved for Health Insurance Marketplace. Advocare coverage expanding in southern Wisconsin FALL

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1 FALL Security Health Plan approved for Health Insurance Marketplace 2013 Security Health Plan is a Qualified Health Plan on the Health Insurance Marketplace created by the federal government as part of the Affordable Care Act. This is an exciting opportunity for Security Health Plan to make a healthy difference in the lives of more Wisconsin residents, said Security Health Plan Chief Administrative Officer Steve Youso. The Affordable Care Act, which is the health care reform law, requires most people to have health insurance on January 1, 2014, either through their employer or purchased directly from a health insurance provider such as Security Health Plan. Beginning October 1, individual and family and small group customers will be able to compare plan options, calculate what tax subsidy they might qualify for, and enroll in a plan at Advocare coverage expanding in southern Wisconsin Security Health Plan is expanding its Advocare Medicare Advantage coverage in southern Wisconsin. The Centers for Medicare and Medicaid Services (CMS) has approved Security Health Plan s request to market its Advocare products in Waukesha, Iowa, Richland and Green counties. Security Health Plan will begin marketing October 1, and will accept enrollment forms for new members from those counties beginning Oct. 15. We re very excited to have earned the opportunity to offer our popular Advocare plans to residents of these four counties, said Chief Administrative Officer Steven R. Youso. We re offering high quality Medicare coverage and extending the list of physicians and specialists our existing members are able to see. Joining Security Health Plan s network of Advocare plan providers, which already included UW-Hospitals and Clinics, Meriter Health Systems and Marshfield Clinic, are these area health care providers: ProHealth Care Monroe Clinic Upland Hills Health Richland Medical Center Sauk Prairie Memorial Hospital and Clinics Reedsburg Area Medical Center (09/13) 2013 Security Health Plan of Wisconsin, Inc.

2 Security Health Plan once again among NCQA s top health plans Thanks in large part to the excellent care our providers give their patients every day, Security Health Plan has again been named one of the nation s best health insurance plans by the National Committee for Quality Assurance (NCQA) for its Medicaid, Medicare and Private plans. This is the ninth consecutive year that Security Health Plan has been recognized by NCQA. Here s how Security Health Plan insurance products rank by category in the NCQA Health Insurance Plan Rankings : Security Health Plan s Advocare Medicare Advantage plans rank 10th in the nation out of 405 plans in NCQA s Medicare Health Insurance Plan Rankings for Security Health Plan s BadgerCarePlus plans rank 12th in the nation out of 131 plans in NCQA s Medicaid Health Insurance Plan Rankings Security Health Plan s commercial plans rank 45th out of 484 plans in NCQA s Private Health Insurance Plan Rankings NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA s Healthcare Effectiveness Data and Information Set (HEDIS ) is the most widely used performance measurement tool in health care. ICD-10 conversions set for October 2014 Security Health Plan is making changes now and will be ready to accept providers ICD-10 claims on October 1, The required conversion from ICD-9 to ICD-10 coding is under way. One goal in setting up our ICD-10 systems is to ensure financial neutrality compared to current claims payments. That means we want claims payment to be accurate, without underpaying or overpaying your ICD-10 claims. Currently we are working on mapping ICD-9 to ICD-10 and updating our systems to be ready to begin testing early in Once our testing schedule is finalized, we will reach out to a sample of providers to schedule specific testing of claims. We are here to help you make a smooth transition to ICD-10. This is a significant conversion for health care providers and insurers. Count on Security Health Plan as a resource and a partner for your successful transition to ICD-10. We re creating a special section on our Provider page that will include ICD-10 materials. You can find answers to some common questions at 2 Provider News Autumn 2013

3 FALL 2013 Security Health Plan s three new medical directors Security Health Plan has three new medical directors, each of whom has experience as a hospitalist, and thus a diverse set of clinical skills. Hospital experience is a key asset as Security Health Plan looks at ways to reduce acute inpatient admissions and readmissions, said Mark LePage, M.D., Security Health Plan chief medical officer. We re pleased to add these fine physicians to our health services team. Their training and experience will be an asset to Security Health Plan. The new medical directors are: Dr. Anupama Inaganti joined Security Health Plan from Marshfield Clinic, where she has been a hospitalist for the last five years, specializing in the treatment of acutely ill patients. Dr. Inaganti completed her Internal Medicine Residency at St. Joseph s Hospital in Marshfield. In addition to her duties with Security Health Plan, Inaganti will continue to treat patients at Marshfield Clinic. That will allow her to keep active on both areas of health care. Anupama Inaganti, M.D. Sumedha Pathak, M.D. Dr. Sumedha Pathak joined Security Health Plan from Ministry St. Joseph s Hospital in Marshfield, where she has been a hospitalist since Dr. Pathak attended medical school in India and completed her Internal Medicine Residency at Ministry St. Joseph s Hospital in Dr. Pathak will split her time between Security Health Plan and continue to practice medicine as a hospitalist at Ministry St. Joseph s Hospital, caring for acutely ill patients. Dr. Sreelatha Chalasani joined Security Health Plan from Marshfield Clinic and Ministry St. Joseph s Hospital where she has served as a hospitalist. Dr. Chalasani attended medical school in India. Her first year of residency was with Lincoln Medical and Mental Health Center in New York City. She finished her residency at Marshfield Clinic and Ministry St. Joseph s Hospital in August Sreelatha Chalasani, M.D. Dr. Chalasani also has a Master s Degree in Public Health from the University of North Texas Health Science Center in Fort Worth, Texas. The three physicians are focusing their time on utilization review/utilization management. Autumn 2013 Provider News 3

4 New B bundle code reimbursement rules for commercial, Security Administrative Services, and Advocare plans Effective November 1, 2013, Security Health Plan will not separately reimburse for Current Procedural Terminology (CPT ) and Healthcare Common Procedure Coding System (HCPCS) codes as identified by the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File with a designated status of B indicating a bundled procedure. Regardless of whether they are billed alone or in conjunction with other services on the same date, B Bundle Codes are not reimbursable services. According to the public use file that accompanies the NPFS Relative Value File, the following is stated for the status indicator of B: Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient). Security Health Plan aims to consistently and accurately process claims for Security Health Plan affiliated providers. Our claims processing system will continue to be updated and maintained to better align with the following industry standards: American Medical Association (AMA) Current Procedural Terminology (CPT ) code sets Healthcare Common Procedure Coding System (HCPCS) code sets International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets, up to 9/30/2014 International Classification of Diseases, 10th Edition/Revision (ICD-10) code sets, for 10/1/2014 and after date of service Centers for Medicare & Medicaid Services (CMS) guidelines National Correct Coding Initiative (NCCI) bundling rules Important Utilization Management changes New Prior Authorization Requirements for Commercial, Security Administrative Services, BadgerCare and Advocare products Security Health Plan is updating utilization management requirements to better align with industry standards. Here are some new prior authorization criteria and steps for completing these required prior authorizations. Referrals to Orthopedist or Neurosurgeon Effective Oct 1, 2013, Security Health Plan is implementing a prior authorization requirement for all referrals to an orthopedic surgeon or neurosurgeon for consultation and/or surgeries for members who have low back pain. As of November 1, 2013, if no prior authorization is obtained and a member completes an orthopedic or neurosurgeon consultation, reimbursement/payment of the consultation and any related services and/or procedures will be denied. The goal of this process is to ensure members have completed optimal conservative treatment for their condition of low back pain. Implementation of shared decision making tool in connection with prior authorization requirement Effective January 1, 2014, Security Health Plan will implement a prior authorization requirement for the (Continued on next page) 3 Provider News Autumn 2013

5 FALL 2013 below requested procedures, with the requirement incorporating a Shared Decision Making Tool for members. The Shared Decision Making Tool utilizes evidence-based clinical criteria which will provide members with the education and information they need to make an informed decision about the surgical care they are seeking to obtain. The provider must obtain prior authorization and the member must complete the Shared Decision Making tool for these requested procedures: total knee replacements total hip replacements all back surgeries If prior authorization has not been obtained by the provider, and the shared decision making tool has not been completed by member, payment for such services will be denied. Security Health Plan will be implementing Shared Decision Making Tool for additional preference-sensitive conditions in the future. You may view a flow chart of this process at Security Health Plan s website at Physical therapy, speech therapy, occupational therapy Effective January 1, 2014, Security Health Plan will fully implement a prior authorization process for outpatient therapies including but not limited to: physical therapy, speech therapy and occupational therapy. Prior authorization is not required for the initial therapy evaluation. If the provider (PT, OT or SLP) does not obtain prior authorization, treatment after the initial-evaluation will be denied as provider responsibility Prior authorization will help assure that outpatient therapy services adhere to medical necessity requirements described in the benefit certificate. Prior Authorization of High-End Imaging Procedures Effective January 1, 2014, Security Health Plan will be implementing a prior authorization process for highend imaging procedures. We are currently developing a relationship with a radiology benefits manager which providers who do not currently use an approved clinical decision support tool. Detailed program requirements will be communicated in the near future. Continued precertification process Security Health Plan will continue to require the precertification process for all of its elective inpatient surgical admissions. Notification of all elective surgical procedures must be completed 14 days prior to the date of the scheduled procedures. Coverage for consultations, outpatient therapies or elective inpatient services is contingent upon member eligibility and all other plan limitations and exclusions. How to contact Security Health Plan to obtain prior authorization Prior Authorization Via Telephone Contact Security Health Plan s Health Services Department at to request prior authorization. Prior Authorization Online Form (Recommended) You can request medical prior authorization via the Provider Portal by following these instructions. When filling out a prior authorization request be sure to include all CPT codes for the procedure(s), and the medical reason why a site of service exception is being requested for the specific office based procedure(s). Go to Enter your Username and Password. (If you do not have a User Name and Password you may obtain one by completing the Provider Portal Access Request Form. Directions for this are below.) Select Authorization Request. Select Medical Request. Enter Member Information. Under Requested Service/Procedure field, select the applicable prior authorization reason. To obtain your username and password for access to Security Health Plan s Provider Portal, complete and submit the form located at: Autumn 2013 Provider News 4

6 Important online information is just a click away You can find important information on services, standards and processes when you visit our Provider and Facility Manuals at When you visit our website, click on Providers, then Provider Manual to learn more about the following topics. You can request a paper copy of any of these topics by calling Security Health Plan s Provider Assistance Line at Clinical practice guidelines for chronic conditions (diabetes, asthma, depression, ADHD, cardiovascular conditions, COPD, nicotine dependence) Preventive service guidelines for patient care An explanation of disease management and case management programs and how to refer patients Completing advance directives Obtaining a Quality Improvement program evaluation Site visit/medical record keeping standards Appointment access standards Medical record documentation standards Utilization management: Obtaining a copy of the criteria used in making decisions, availability and how to contact medical director/pharmacist, how to contact the department, non-compensation statement, timeliness of decisions New technology; evaluation process and coverage decisions Pharmacy management procedures; Formulary, exception process, prior authorization Statement of Members Rights and Responsibilities; member complaints and appeals procedures Security Health Plan medical record-keeping standards Security Health Plan has established site performance standards and thresholds for physical accessibility, physical appearance, adequacy of waiting and examining room space and adequacy of medical/treatment record keeping for affiliated practice locations. These standards can be found in the Security Health Plan Credentialing Program Manual located on our website at If you prefer a paper copy of these standards, you may contact Security Health Plan Provider Relations and Contracting at Provider News Autumn 2013

7 FALL 2013 Our new website was created with you in mind We re unveiling a new look for our Security Health Plan website. You ll find our new website more complete and easier to navigate. It s been created to be viewed on any device home computer, tablet, smart phone - with modern internet viewing habits in mind. The long-scrolling page is a contemporary design based on how people use web pages and other digital media. We spent the past few years understanding who our website audiences are, how they use websites in general, and what they want from our website. Our new web design is based on extensive research and planning based on that research, said John Kelly, chief marketing officer. This is really a first step in a carefully planned multi-phase, multi-year strategy that will help Security Health Plan move fully into the contemporary digital age. There s more to come. Our new website features: Up-to-date information about health care reform Easy to access Provider tools and resources Timely news you ll find valuable to your practice Regular updates about the ICD-10 conversions Providers come to our website with a purpose. This new design will make it easier for them to get the information they need, Kelly said. We want our new website to be accessible, friendly and useful. Let us know what you think. An easy, fast way to check claim status Our customer service representatives are always pleased to help you when you need to review claim status, But thanks to secure , providers have another way to check on claim status that avoids being put on hold while a customer service representative manually looks up that information: Step 1 Go to our Provider section and click on Provider Tools and Resources Step 2 In the Claims area, click on Claims Status Inquiry Step 3 Copy and paste the information that you need into the Step 4 Sending a secure will be simpler and faster for you and for us Autumn 2013 Provider News 6

8 FEATURED INSIDE Security Health Plan approved for Health Insurance Marketplace Advocare plans expanding in southern Wisconsin Important utilization management changes New B bundle code reimbursement rules Once again among nation s top health plans Preparing for 2014 ICD-10 conversions Introducing our new website and more! Provider News: Security health Plan s Provider News is intended to keep providers in our network current with the latest developments in group and direct pay, Medicare, Medicaid and other managed care programs. You can view an electronic version of the newsletter on our provider portal. If there is a topic you would like addressed in Provider News, please contact Terry Anderson, editor, at North Saint Joseph Avenue P.O. Box 8000 Marshfield, WI Nonprofit Org. U.S. Postage PAID Security Health Plan of Wisconsin, Inc.