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Table of contents3Introduction22Claim filing proceduresPrimary Care Providers (PCPs)4Telephone directory5Online servicesUsing the SafeGuard Wisconsin Provider Web Portal7Member informationSample ID cardEligibility/benefit verificationNetwork information and Benefit Levels10Utilization management programServices requiring prior authorizationServices not requiring prior authorizationPrior authorization of inpatient admissionsInpatient prior authorization requirementsHow to obtain prior authorizationHow to submit a prior authorization requestSubmitting prior authorizations by faxSubmitting prior authorizations by phoneClinical information submission requirementsUtilization management appeal processList of services requiring prior authorizationPrescription drug coverageFind an in-network pharmacyAnesthesiology providersMid-Level providersPayment for multiple proceduresPayment for professional services (Modifier 26)Provider reimbursement rules/sample Explanationof BenefitsZelis TM paymentsClaims status inquiry processClaim adjustments29Post-service appeal process30Provider forms and resourcesSafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 2Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.

IntroductionWe’re pleased to work with you as a provider for SafeGuard Wisconsin. This manual contains information on SafeGuardWisconsin policies and procedures to help you as you provide services to covered SafeGuard Wisconsin members.We believe that the best health care comes from a partnership between the patient, the physician and the health plan.When we work together and support each other in the commitment to patient care, we can achieve positive healthoutcomes, 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.Every member of the coordinated healthcare team above is continually working to enhance our service to you and yourorganization. We value your comments and feedback.SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 3Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.

Telephone directoryDepartmentContact informationProvider Services: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 ofthe member’s ID card. Confirm member eligibility Confirm benefit information Verify copayment and deductibles24/7 Automated System:See member ID card forautomated numberClaim Inquiries For specific claim inquiries contact the customer service number on the backof the member’s ID card.See member ID card fornumberClaims mailbox for SafeGuard Wisconsin:PO Box 321125Detroit, MI 48232-1125Electronic Payments (Zelis)(877) 828-8770Utilization Management (eQHealth)8:00 AM – 8:00 PM (ET) Monday – Friday Request pre-certification of a service Report clinical information Submit Appeals Questions regarding the Utilization Management Program866-356-3666Pharmacy Benefits24 hours / 7days(800) 424-5850Fax:(586) 693-4829SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 4Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS 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.SafeGuard Wisconsin Provider Web PortalGo to: 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 WisconsinProvider Web Portal must have a username and password. To obtain a SafeGuard Wisconsin Provider Web Portal username andpassword, download the application from the website and return itto SafeGuard Wisconsin. Each form allows several individual users torequest access. After you log in, follow the instructions on “How to Use This Site” onleft side of screen.Make sure your authorized user list is up to date: To see which individuals from your office already have usernamesand passwords, or to remove a user who is no longer employed byyour office, contact SafeGuard Wisconsin at 586-693-4393.Submit Claims Electronically:SafeGuard Wisconsin claims can be electronically submitted using the following vendor: RelayHealth - McKesson.Use Payor ID 38259.SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 5Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.

Using the SafeGuard Wisconsin Provider Web Portal To access the SafeGuard Wisconsin Provider Web Portal:1. Go to the SafeGuard Wisconsin Login page at:safeguardwisconsin.com/login/ and choose “ Providers ”.This will take you to your login screen at the SafeGuardWisconsin Provider Web Portal.2. On the SafeGuard Wisconsin Provider Web Portallanding page, enter your Username and Password.3. On the Home screen, you can select Eligibility, Claims,Authorizations, or Resources . Eligibility : Search for a patient by Member IDnumber or last name and DOB. Claims : Search for a claim by Member ID numberor Claim number. Authorization : Search for a patient’sauthorization by Member ID number orAuthorization number. Resources : Additional tools and information.SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 6Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS 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.FRONTMedical Claims SubmissionsSubmit claims directly to the claims payers for SafeGuard WisconsinHealth on the back of the card.BACKSubmit claims to:- EDI Payor #38259- SafeGuard WisconsinP.O. Box 321125Detroit, MI 48232-1125SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 7Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS 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.Verifying member eligibilityAs a network provider, you can contact SafeGuardWisconsin to: Check benefits coverage. Verify eligibility.Online: Visit safeguardwisconsin.com/login/ Log into the SafeGuard Wisconsin ProviderWeb Portal with your SafeGuard Wisconsinsupplied username and passwordBy Phone: For automated 24/7 service, see memberID card for phone number and follow the promptsfor our Faxback ServicesSafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 8Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS 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 PPO and 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 NetworkMembers receive the best value and highest level of benefits when they receive care from SafeGuard WisconsinHealth ministries and their contracted providers.Out-of-NetworkIf members use providers who are not members of the primary network, they will get the lowest benefit level andwill be responsible for higher out-of-pocket costs. EPO plans do not cover out-of-network providers, therefore EPOplan members must cover 100% of the costs from out-of-network providers.Out-of-Network (Tier 3)If members are referred to facilities that offer rare specialized care those members will be considered as using thePrimary Network when Prior Authorization is obtained.SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 9Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.

Utilization management programSafeGuard Wisconsin partners with eQHealth to administer their utilization management. The utilization management(UM) philosophy and approach utilized by eQHealth is to provide high quality and cost effective health care. The UMprogram has a two-fold approach involving both the member and provider. By applying Managed Care principles, themember is ensured the right level of care, by the right provider, in a safe, high-quality, cost effective manner. The UMprogram is designed to also achieve provider satisfaction, efficiency and effectiveness.The purpose of the UM program is to ensure appropriate, safe, high quality, cost effective services for all members inboth 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 concurrent review.This requirement applies to all physicians and facilities, regardless of the provider’s network contract. Certain outpatient surgeries, treatments, services and durable medical equipment High Tech Radiology (MRI, MRA, PET and certain nuclear scans)Services not requiring prior authorizationPrior authorization is required ONLY for the services listed on the 2021 Prior Authorization Code List. If a request issubmitted for services that do not require prior authorization, a response will be sent back to the provider. If you donot receive a response, please check to make sure the service requires prior authorization before submitting a secondrequest.Providers must obtain prior authorization from the SafeGuard Wisconsin Utilization Management Department beforethe admission or service is provided. These prior authorization requirements apply when: SafeGuard Wisconsin is considered primary or secondary coverage unless otherwise noted in this document The admission or service is elective or direct/urgent The service is inpatient or outpatientThese requirements DO NOT apply to members who have Medicare as primary coverage.SafeGuard Wisconsin Health Provider Manual – Effective January 1, 2021 – 10Excess loss insurance policies and EPO/PPO insurance plans underwritten by US Health and Life Insurance Company. SafeGuard plans administered byUS Health and Life Insurance Company. US Health and Life Insurance Company. All rights reserved.

Prior authorization of inpatient admissionsInpatient prior authorization requirementsThe 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 Care High risk and maternity (only if inpatient stay exceeds federal requirements) Inpatient Rehabilitation Inpatient, residential, intensive outpatient, and partial hospitalization for Mental Health & Substance Abuse Long term acute care Skilled nursing and sub-acute facilities Inpatient hospiceHow to obtain prior authorization for inpatient staysTo obtain prior authorization for inpatient stays, please submit the request viathe eQHealth Provider Portal or fax the following information to 586-693-4829 . For future, elective admissions , please submit the completed 2021 PriorAuthorization form along with the supporting documentation as soon aspossible or at least 14 business days prior to the admission date for allelective, inpatient admissions. For ALL inpatient admissions (elective & emergent) , please submit thecompleted 2021 Prior Authorization form, the facility demographic facesheet and medical records within two business days of admission fromthe admitting facility.Any inpatient admission from an In-Network or Out-of- Network facility not priorauthorized w