Back to Find A Plan Show Out-of-network liability and balance billingHow to receive services from non-network health care providers Unless your health plan, as specified in your Schedule of Benefits, provides access to non-network providers, services provided by non-network health care providers generally are not covered by Security Health Plan. However, benefits may be payable for services by a non-network health care provider if Security Health Plan determines that the service is not available from any network health care provider or as stated in your Schedule of Benefits. For a service that requires prior authorization, have your health care provider contact Security Health Plan before the service is provided. With the exception of emergency or urgent care services, Security Health Plan will not pay for a service that has already been provided by a non-network health care provider, unless otherwise stated in a member’s Schedule of Benefits. All of the following criteria for prior authorization must be met:
When a member receives prior authorization for a service from a non-network health care provider, the prior authorization will state the type or extent of evaluation and/or treatment authorized, the number of authorized visits, the period during which the prior authorization is valid and the location for services. Any additional services recommended by and received from a non-network health care provider are not covered unless prior authorization is given. Except for urgent and emergent care, reimbursement is limited for non-network benefits to the Usual, Customary, and Reasonable charges for cost-effective services, subject to applicable deductible, coinsurance and copayment amounts. If a charge exceeds our Usual, Customary, and Reasonable fee schedule, Security Health Plan may reimburse less than the billed charge and the member is responsible for any amount charged in excess of such fees, as well as applicable deductible, coinsurance and copayment amounts. Remember: a recommendation or referral by a network health care provider to receive services from a non-network health care provider is not covered unless prior authorized by Security Health Plan or otherwise stated in a member’s Schedule of Benefits. Please have your health care provider contact Security Health Plan before you receive non-emergency or non-urgent services from non-network health care providers. Enrollee claims submissionClaims Processing Procedure Types of claims There are four categories of claims that can be made under this plan. The primary difference between these categories is the timeframe for determination and appeal. It is very important to follow the requirements that apply to your type of claim. If you have questions about these Claims Processing Procedures or what type of claim you have, contact Security Health Plan's Customer Service Department at 1-800-472-2363. The four categories of claims are:
The claim type is determined initially when the claim is filed. However, if the nature of the claim changes as it proceeds through the claims process, the claim may be re-characterized. For example, a claim may initially be an urgent care claim. If the urgency subsides, then it may be re-characterized as a pre-service claim. Proof of claims The member, or the health care provider on the member’s behalf, must submit written proof of the claim for each service to Security Health Plan within 90 days of the date on which the member received the service. Written proof of the member claim includes:
In accordance with Wisconsin law, if circumstances beyond the member’s control prevent the member from submitting such proof to Security Health Plan within this time period, Security Health Plan will accept a proof of claim, if provided as soon as possible and within one year after the 90-day period. If Security Health Plan does not receive the written proof of claim required by Security Health Plan within that one-year-and-90-day period, no benefits are payable for that service. Filing a claim In most cases, the health care provider submits claims directly to Security Health Plan. However, a member may also submit a claim if the provider does not accept Security Health Plan insurance. A claim will be treated as received by Security Health Plan (a) on the date it is hand-delivered to Security Health Plan at the indicated address; or (b) on the date that it is received by the health plan. Claims must be submitted by the applicable deadlines
for the type of claim as indicated in these procedures. Unless otherwise indicated, when used in these claims procedures, the term “day” means a calendar day. Members can fax, mail or email the information to: Security Health Plan Claims should be accompanied by proof of the claim. In light of the expedited time frames for urgent care claims, an urgent care claim for benefits may be faxed to 715-221-6616. A claim will be treated as received by Security Health Plan (a) on the date it is hand-delivered to Security Health Plan at the indicated address; or (b) on the date that it is received by the health plan. Claims must be submitted by the applicable deadlines for the type of claim as indicated in these procedures. Unless otherwise indicated, when used in these claims procedures, the term “day” means a calendar day. Grace periods and claims pending policies during the grace period When coverage ends Security Health Plan can terminate coverage for members who do not pay their premiums. Members who receive tax credits through the Marketplace have a 90 day grace period to allow you catch up with any late payments. Members who do not receive tax credits through the Marketplace have a 10-day grace period in which to make a payment. Payments are needed for any past due amount to prevent disenrollment. Please be aware that disenrollment will not only affect the subscriber, but all enrollees who receive coverage through your policy. Claims are only paid during the first month of the grace period and then will be pended during the remaining two months, unless the member exits the grace period by making the required premium payment. While claims are being pended, providers may still submit claims to Security Health Plan but they will be held for processing. If sufficient payment to exit the grace period is received, these held claims will be processed according to benefits. If sufficient payment is not received and the policy is terminated for non-payment, the held claims will be denied by Security Health Plan and returned to providers. If Security Health Plan does not receive a member’s payment, the coverage of a member receiving APTC will end as of the end of the first month of grace. A member who does not receive APTC will have coverage end as of the end of the last paid month. Retroactive denialsThe consequences of losing coverage include:
If a member fails to pay his/her premium, the next month they will receive a past due premium statement advising that they have entered their first month of grace. The past due premium statement will be accompanied by a letter that advises the member of the grace period and consequences of losing coverage, including responsibility for paying any medical claims incurred during the period of retroactively terminated coverage. Security Health Plan retains the right to recover excess claim payments made in certain situations, including payment for services already received from your provider. Familiarize yourself with services covered by your plan, and any rules you must follow regarding those covered services. Always contact Security Health Plan before you receive any medical care, to verify coverage and avoid unforeseen bills.
Recoupment of overpaymentsWhen a subscriber has overpaid their premiums, a credit of the overpayment will be reflected on their account and applied to future premiums due. To request a refund, please contact our Customer Service team by calling 844-293-9624 or 715-221-9258, Monday through Friday, 7:00 a.m. - 5:30 p.m. or email . All refund requests must be made by the subscriber and will be returned to the subscriber in the form of the original payment. Refunds may take up to 60 days for the subscriber to receive from the date of the request due to processing. Overpayments are not automatically refunded on active accounts unless requested by the subscriber. Medical necessity and prior authorization time frames and enrollee responsibilitiesTo be eligible for coverage, there are certain medical services and prescription drugs for which you or your provider are required to contact Security Health Plan and receive an approved prior authorization before you receive the service or care. These may include services, such as pain management, spinal surgery, new technologies (may be considered experimental/ investigational/ unproven), non-emergency ambulance, durable medical equipment, certain high-technology imaging, or procedures that could potentially be considered cosmetic. You can find a current list of health care services for which prior authorization is required in your Schedule of Benefits. You can also visit our website at www.securityhealth.org/authorization or call our Customer Service Department at 1-800-472-2363 to find out what services require prior authorization. How to request a prior authorization Your health care provider can start the prior authorization process by downloading a printable prior authorization form from our website at www.securityhealth.org/authorization and entering the prior authorization on the provider portal, faxing it to 715-221-6616, or calling our Provider Assistance line at 1-800-548-1224. After the health care provider submits a prior authorization request, we suggest that you check My Security Health Plan, online at www.securityhealth.org to verify the status. Except in the case of a prior authorization request that is deemed urgent, please allow up to 14 business days for the review process. Although your health care provider should initiate the prior authorization process, it is your responsibility to ensure that: a. The prior authorization request form is obtained and completed in consultation with your health care provider. After we review your request, we will send a written response to you and/or the health care provider who submitted the request. Our benefit determination(s) will be based upon the information available to us at the time we receive your request. If we approve your request, our prior authorization will only be valid for: a. The covered
person for whom the prior authorization was made. Consequences for failing to obtain a prior authorization Failure to comply with the prior authorization process outlined in this subsection will result in no benefits being paid under the policy. Please refer to your Schedule of Benefits for a list of required prior authorizations. Drug exceptions timeframes and enrollee responsibilities
External Prescription Request Review: If Security Health Plan denies a request for a standard exception or for an expedited exception, you, your authorized representative or the prescribing provider can request the original exception request and subsequent denial be reviewed by an independent review organization. If Security Health Plan grants an external exception review of a standard exception request, we must provide coverage of the non-formulary drug for the duration of the prescription. If Security Health Plan grants an external exception review of an expedited exception request, we must provide coverage of the non-formulary drug for the duration of the exigency. Please review your member materials or call our Customer Service department at 1-800-472-2363 for more information about this process. Explanation of benefits (EOB)Personal Health Statement An Explanation of Benefits (EOB) is Security Health Plan’s written explanation of a claim and is not a bill. Security Health Plan refers to our EOB as a Personal Health Statement (PHS). The Personal Health Statement explains the services received and the date of service, the amount billed for services, the amount saved if using Security Health Plan coverage, the amount Security Health Plan has paid, the amount any other insurance has paid and any balance the member is responsible to pay. Figuring out who pays the bills? After a member receives medical services, the health care provider sends a claim to Security Health Plan. Security Health Plan determines how much of the claim is owed to the provider based on the member’s specific plan’s coverage and discounts Security Health Plan has negotiated on the member’s behalf with the provider. Members will then receive a Personal Health Statement. The provider will also send a bill letting the member know what amounts may still be owed. Personal Health Statement Sample Coordination of benefits (COB)When members have more than one plan How this applies to you This section applies to this plan when a member or a member’s covered dependent has health care coverage under more than one plan. Plan: any of the following that provides benefits or services for medical or dental care or treatment:
This plan: the part of the policy that provides benefits for health care expenses. The order of benefit determination rules below govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100 percent of the total allowable expense. Order of benefit determination rules General – When there is a basis for a claim under this plan and another plan, this plan is a secondary plan that has its benefits determined after those of the other plan, unless those rules and this plan’s rules described below require that this plan’s benefits be determined before those of the other plan. Rules – this plan determines its order of benefits using the first of the following rules which applies:
However, if the other plan does not have the rules described above but instead has a rule based upon the gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan shall determine the order of benefits.
Effect on the benefits of this plan This subsection applies when, in accordance with “Order of Benefit Determination Rules,” this plan is a secondary plan as to one or more other plans. In that event, the benefits of this plan may be reduced under this subsection. Such other plan or plans are referred to as “the other plans.” The benefits of this plan will be reduced when the total benefits payable exceeds the allowable expenses in a claim determination period. When the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan. Right to receive and release needed information Security Health Plan has the right to decide which facts it needs to apply these Coordination of Benefits (COB) rules. It may get needed facts from, or give them to, any other organization or person without the consent of the insured but only as needed to apply these COB rules. Medical records remain confidential as provided by federal and state law. Each person claiming benefits under this plan must give Security Health Plan any facts we need to pay claims. What is not included in Social Security?Pension payments, annuities, and the interest or dividends from your savings and investments are not earnings for Social Security purposes. You may need to pay income tax, but you do not pay Social Security taxes.
Who does not benefit from Social Security?Some American workers do not qualify for Social Security retirement benefits. Workers who don't accrue the requisite 40 credits (roughly 10 years of employment) are not eligible for Social Security. Some government and railroad employees are not eligible for Social Security.
Which are reasons not to depend on Social Security as a retirement plan?You won't have enough money
Social Security will replace only 40% of preretirement earnings, when retirees typically need twice that amount. Unless you want to drastically slash spending upon retirement, Social Security can't fund your later years.
Which is not true regarding Social Security?Which statement is NOT true regarding Social Security benefits? Social Security Disability benefits are NOT designed to replace 100% of the worker's earnings.
|