Provider News - August 2026

REQUIREMENTS - MULTIPLE EFFECTIVE DATES: 1. BY SEPTEMBER 15, 2026 (before Oct 1, 2026 effective date): Billing team must audit all Medicare claims submitted with modifier 78 (Unplanned Return to OR) to understand current claim volume and reimbursement rates. Alert providers that Security Health Plan will reduce Medicare reimbursement for modifier 78 claims processed on or after October 1, 2026, to align with CMS guidelines. Review claim submission practices to ensure modifier 78 is used only when clinically appropriate. 2. BY DECEMBER 1, 2026 (before Jan 1, 2027 effective date): Billing team must implement new itemized billing structure for maternity care services. Remove global maternity care codes from billing system templates and encounter forms. Coordinate with providers to transition documentation to support itemized billing. Contact Security Health Plan for specific code mappings and billing guidance. Failure to transition will result in claim denials for maternity services submitted under old global coding structure. 3. BY DECEMBER 15, 2026 (before Jan 1, 2027 effective date): Identify all patients enrolled in Security Health Plan SSI Medicaid coverage. Notify affected members they must transition to a new health plan for 2027 coverage. Coordinate with plan to understand transition process and ensure continuity of care. This does not impact BadgerCare Plus members. 4. IMMEDIATELY: Review pharmacy prior authorization (PA) and post-service claim edits (PSCE) updates from Prime Therapeutics for office-administered, medically billed medications. Update billing system rules and obtain complete list of affected medications. Ensure front-end staff request prior authorization before services when required. Document new PSCE requirements to prevent unexpected claim denials. 5. ONGOING: Billing team should use Security Health Plan Provider Portal to submit all prior authorization requests electronically to receive faster decisions and reduce processing delays.