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PROVIDER MANUALGeneral Information for Participating ProvidersRevised November 22, 2019
TABLE OF CONTENTSINTRODUCTION4ONLINE SERVICES5Using the SafeGuard Wisconsin Provider Web PortalTELEPHONE DIRECTORYPhone NumberMEMBER INFORMATION6889Sample ID CardEligibility / Benefit Verification910Network information and Benefit Levels11UTILIZATION MANAGEMENT12Overview12Purpose12Services Requiring Prior Authorization12Services Not Requiring Prior Authorization12Prior Authorization of Inpatient Admissions13Exceptions14How to Obtain Prior Authorization15How to Submit a Prior Authorization RequestClinical Information Submission Requirements (15 days prior to service):1617Utilization Management Appeal Process18List of Services Requiring Prior Authorization20PRESCRIPTION DRUG COVERAGEPrescription Drug Program Highlights:CLAIM FILING PROCEDURES222224How to File a Medical Claim24Primary Care Providers26Anesthesiology Providers26Mid-Level Providers26Payment for Multiple Procedures27Payment for Professional Services (Modifier 26)27Provider Reimbursement RulesSample Explanation of Benefits (EOB)2728Zelis TM Payments29Page 2SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
Claims Status Inquiry Process30Claim Adjustments31Post Service Appeal Process32APPENDIXProvider Forms & ResourcesPage 3SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.3334
INTRODUCTIONWe’re pleased to work with you as a provider for SafeGuard Wisconsin. This manual contains information onSafeGuard Wisconsin policies and procedures to help you as you provide services to covered SafeGuard Wisconsinmembers.We believe that the best health care comes from a partnership between the patient, the physician and the healthplan. When we work together and support each other in the commitment to patient care, we can achieve positivehealth outcomes, make sure both patients and providers have satisfying experiences, and keep costs affordable.SafeGuard Wisconsin is continually working to enhance our service to you and your organization. We value yourcomments and feedback.Page 4SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
ONLINE SERVICESSafeGuard Wisconsin Providers have 24/7 access to manage claims and benefits through the US Health and Life(SafeGuard Wisconsin) Provider Web Portal.Access the SafeGuard Wisconsin Provider Web Portal by choosing “Providers” at:https://safeguardwisconsin.com/login/ .Use the SafeGuard Wisconsin Provider Web Portal to: Confirm member eligibility and benefits Check claim status and claims historyAccess Requirements: Each person in your office who needs to use the SafeGuard Wisconsin Provider Web Portal must have ausername and password. To obtain a SafeGuard Wisconsin Provider Web Portal username and password, download the applicationfrom the website and return it to SafeGuard Wisconsin. Each form allows several individual users to requestaccess. After you log in, follow the instructions on “How to Use This Site” on left side of screen.Make sure your authorized user list is up to date: To see which individuals from your office already have usernames and passwords, or to remove a user whois no longer employed by your office, contact SafeGuard Wisconsin at 586-693-4393.Submit Claims Electronically:SafeGuard Wisconsin claims can be electronically to using the following vendor: RelayHealth - McKesson. Use PayorID 38259.Page 5SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
Using the SafeGuard Wisconsin Provider Web PortalTo access the SafeGuard Wisconsin Provider Web Portal:1. Go to the SafeGuard Wisconsin Login page at: https://safeguardwisconsin.com/login/ and choose “Providers”.This will take you your login screen at the SafeGuard Wisconsin Provider Web Portal.2. On the SafeGuard Wisconsin Provider Web Portal landing page, enter your Username and Password.Page 6SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
3. On the Home screen, you can select Eligibility, Claims, Authorizations, or Resources . Eligibility : Search for a patient by Member ID number or last name and DOB. Claims : Search for a claim by Member ID number or Claim number. Authorization : Search for a patient’s authorization by Member ID number or Authorization number. Resources : Additional tools and information.Page 7SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
TELEPHONE DIRECTORYServicePhone NumberProvider Service : 8:30 AM – 4:30 PM (ET) Monday – Friday Request copy of Provider Manual Request fee schedule allowable amounts Request assistance resolving fee schedule issues(844)-659-2518For questions regarding the following, use our customer service department’s 24/7Automated faxback system by calling the Customer Service Number on the back of themember’s ID card. Confirm member eligibility Confirm benefit information Verify copayment and deductibles24/7 AutomatedSystem:See member IDcard for automatednumberClaim Inquiries For specific claim inquiries contact the customer service number on the back of themember’s ID card.Claims mailbox for SafeGuard Wisconsin:PO Box 321125Detroit, MI 48232--1125Electronic Payments (through electronic payment vendor - Zelis)Utilization Management (eQHealth) 8 :00 AM – 8:00 PM (ET) Monday – Friday Request Prior Authorization of service Notify carrier of in-patient admissions Report clinical information Questions regarding the Utilization Management Program Submission & management of appealsSee member IDcard for numberPharmacy Benefits (800) 424-5850Page 8 24 hours / 7 days(877) 828-8770(866) 356-3666Fax: (586) 693-4829SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
MEMBER INFORMATIONSample ID CardPlease request a copy of the individual member’s ID card.SafeGuard Wisconsin ID Card SamplePage 9SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
Eligibility / Benefit VerificationProviders are responsible to confirm eligibility on the date of service and determine benefit coverage for all servicesprovided.As a network provider, you can contact SafeGuard Wisconsin to: Check benefits coverage. Verify eligibility.OnlineContact SafeGuard Wisconsin at https://safeguardwisconsin.com/login/ . Log into the SafeGuard Wisconsin Provider Web Portal with your SafeGuard Wisconsinsupplied username and password.PhoneFor automated 24/7 service, see member ID card for phone number and follow the promptsfor our Faxback ServicesPage 10SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
Network information and Benefit LevelsSafeGuard Wisconsin offers medical coverage for employers under insurance policies issued by US Health and LifeInsurance Company and self-funded benefit plans administered by US Health and Life under the SafeGuard program.SafeGuard Wisconsin PPOand EPO plans offer members two levels of benefits, depending on the providers they use.EPO plans use the Ascension Network as their primary network, while PPO plans have a more expansive network. Primary Network : Members receive the highest level of benefits when they receive care from a primarynetwork provider. Out-of-Network: If members use providers who are not members of the primary network, they will get thelowest benefit level and will be responsible for higher out-of-pocket costs. EPO plans do not coverout-of-network providers, therefore EPO plan members must cover 100% of the costs from out-of-networkproviders. Rare Specialized Care Providers: If members are referred to facilities that offer rare specialized care thosemembers will be considered as using the Primary Network when Prior Authorization is obtained.Page 11SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
UTILIZATION MANAGEMENTOverviewSafeGuard Wisconsin partners with eQHealth to administer their utilization management. The utilizationmanagement (UM) philosophy and approach utilized by eQHealth is to provide high quality and cost effective healthcare. The UM program has a two-fold approach involving both the member and provider. By applying Managed Careprinciples, the member is ensured the right level of care, by the right provider, in a safe, high-quality, cost effectivemanner. The UM program is designed to also achieve provider satisfaction, efficiency and effectiveness.PurposeThe purpose of the UM program is to ensure appropriate, safe, high quality, cost effective services for all membersin both the inpatient and outpatient setting.The utilization management program identifies services for clinical review by analyzing utilization data and takes intoconsideration: Benchmark data and quality measures such as HEDIS Consistent application of clinical evidence Plan goals and objectives High cost/high volume procedures Opportunities to improve care Medical Director and provider recommendations Potential for abuse/misuse of service or procedure Evaluation of cost savingsServices Requiring Prior AuthorizationThe SafeGuard Wisconsin medical plan requires prior authorization for the following services: All inpatient admissions to any acute/subacute care facility require prior authorization and concurrentreview. This requirement applies to all physicians and facilities, regardless of the provider’s networkcontract.Certain outpatient surgeries, treatments, services and durable medical equipmentHigh Tech Radiology (MRI, MRA, PET and certain nuclear scans)Services Not Requiring Prior AuthorizationPrior authorization is required ONLY for the services listed on the 2020 Services Requiring Prior Authorization list. If arequest is submitted for services that do not require prior authorization, a response will be sent back to theprovider. If you do not receive a response, please check to make sure the service requires prior authorization beforesubmitting a second request.Page 12SafeGuard Wisconsin Provider Manual – Revised November 22, 2019Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plansadministered by US Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.
Providers must obtain prior authorization from the SafeGuard Wisconsin Utilization Management Departmentbefore the admission or service is provided. These prior authorization requirements apply when: SafeGuard Wisconsin is considered primary or secondary coverage unless otherwise noted in this documentThe admission or service is elective or direct/urgentThe service is inpatient or outpatientThese requirements DO NOT apply to members who have Medicare as primary coverage.Prior Authorization of Inpatient AdmissionsThe Inpatient Prior Authorization program requires that all inpatient admissions are authorized within two businessdays of admission. The components of inpatient prior authorization include those services listed below. Acute CareHigh risk and maternity ( only if inpatient stay exceeds federal requirements)Inpatient RehabilitationInpatient, residential, intensive outpatient, and partial hospitalization for Mental Health & Substance AbuseLong term acute careSkilled nursing and sub-acute facilitiesInpatient hospiceTo obtain prior authorization for inpatient stays, please submit the request via the eQHealth Provider Portalor fax the following information to 586-693-4829. For future, elective admissions, please submit the completed 2020 Prior Authorization form along withthe supporting documentation as soon as possible or at least
Using the SafeGuard Wisconsin Provider Web Portal 6 TELEPHONE DIRECTORY 8 Phone Number 8 MEMBER INFORMATION 9 Sample ID Card 9 Eligibility / Benefit Verification 10 Network information and Benefit Levels 11 UTILIZATION MANAGEMENT 12 Overview 12 Purpose 12 Services Requiring Prior Authorization 12 Services Not Requiring Prior Authorization 12 Prior Authorization of
