Medicare AdvantageAdministrativeHigh impact
Provider News - October 2023
Security Health Plan·WI · Cardiology, Radiology, Psychiatry +4 more·Provider News
We identified it
Jun 20, 2026
Summary
Security Health Plan October 2023 Provider News contains multiple operational updates affecting billing and prior authorization workflows. Key changes include: (1) eviCore healthcare portal transitioning to a new online system for radiology and cardiology prior authorizations currently on MedSolutions; (2) new pharmacy prior authorization and post-service claim edit requirements effective 2024; (3) Medicare Advantage reimbursement requirements for critical access hospitals, swing beds, and rural health clinics based on CMS rate letters; (4) Optum now handling bill review for claims exceeding $100,000; (5) COVID-19 vaccine commercialization affecting billing when federal supply exhausts; and (6) updated Medicaid guidelines for behavioral health and AODA services by qualified treatment trainees.
Action Required
REQUIREMENTS - Multiple staggered deadlines:
1. IMMEDIATELY - Pharmacy & Prior Auth Team: Review Security Health Plan website (www.securityhealth.org/prescriptiontools) monthly by the fifth business day to identify new 2024 pharmacy prior authorization and post-service claim edit requirements. Update billing software rules and encounter templates to enforce these requirements before processing 2024 claims. Non-compliance will result in claim denials and payment delays.
2. Before 2024 Implementation: Billing team must coordinate with pharmacy to document all new PA and post-service claim edit requirements for medications. Distribute updated guidance to clinical and coding staff. Failure to implement will cause coverage denials.
3. IMMEDIATE (Fall 2023): Billing team must update COVID-19 vaccine billing procedures to prepare for commercialization. When federal vaccine inventory exhausts (expected fall 2023), stop billing vaccines as federally supplied. Switch to commercial vaccine billing with appropriate CPT/HCPCS codes and cost allocation. Verify vaccine supply status monthly with your practice's vaccine distributor.
4. Medicare Advantage Reimbursement: For critical access hospitals, swing beds, and rural health clinics billing Medicare Advantage through Security Health Plan, billing team must verify current CMS rate letter on file with payer. Contact Security Health Plan Provider Relations (715-221-9640) to confirm CMS rate letter is current before submitting claims. Incorrect rate letters result in underpayment.
5. Claims Over $100,000: Billing team must be aware that Optum will contact you on behalf of Security Health Plan to request UB-04 forms, itemized charges, and medical records for claims exceeding $100,000. Establish process to respond promptly to Optum requests to avoid claim delays.
6. Radiology & Cardiology Prior Auth: Monitor Security Health Plan communications for eviCore healthcare new portal launch announcement. Update prior authorization submission process to transition from MedSolutions to new eviCore portal when available. Update staff training materials and encounter workflows.
7. Medicaid - Behavioral Health/AODA: Billing team must review updated guidelines for qualified treatment trainee (QTT) billing. Ensure proper documentation and billing codes are applied per updated requirements. Verify providers are documenting QTT credentials appropriately.