Dear Colleagues,
Recently, I had the honor of accepting the Leading Change, Creating Value Award from the Business Health Care Group on behalf of WPS Health Solutions, our parent company.
The award recognized WPS for our commitment to improving health care transparency, quality, and cost efficiency. These are goals we don't take lightly. For more than 70 years, we have been committed to providing value to the customers and communities we serve, as well as partners such as yourself.
I hope you'll find this issue valuable. It includes details on how to access and use the new secure messaging functionality within our provider portal. Additionally, you can learn more about the following:
- Our updated Provider Manual
- Member rights and responsibilities
- Medical policy guidelines
We appreciate the care you give your patients and our customers. If you have any questions, please contact me by email at
Jonah.Fox@wpsic.com
or by phone at 608-977-8038.
Sincerely,
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Jonah Fox, M.D., M.H.A.
Medical Director
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Secure messaging is available
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Did you know that Arise offers a secure way for you to contact Customer Service directly via the provider portal? Secure messages are similar to email, but they can be accessed only through the Arise online health portal. You are allowed up to 4,000 characters for your secure message.
To use secure messaging, go to the Provider section on the website and then click the
Sign In
button. Along with your question, please provide:
- Patient's full name
- Member identification number or SSN
- Date of birth
- One of the following:
- Last four digits of SSN, if SSN was not given above
- Full address, including the city, state, and ZIP code
- Full phone number, including area code
When you use our Secure Message Center, you will typically receive a reply within three business days. When a reply has been sent, you will receive a notification on your provider dashboard.
If you are not currently using our provider portal, you may register by visiting the link below. Complete the form in its entirety by entering your demographic, practice, and account information.
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Provider Manual revised for 2020
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Our Provider Manual has a fresh new look! Check out our website for the updated
2020 Provider Manual
. Revisions include additional information about our Credentials Verification Organization (CVO), called Eddy, and updated contact information. Our Provider Manual is designed and produced for our participating providers to promote a clear understanding of our policies and procedures including:
- Prior authorizations
- Claims
- Eligibility
When accessing the Provider Manual, please refer to our website for the most up-to-date information, policies, and procedures.
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Contact us with authorization denial notices
If you have questions when you receive a denial notice for services, contact our Integrated Care Management team to review medical policy guidelines and/or discuss determination rationale.
The Integrated Care Manager (ICM) who initially reviewed the service can discuss the medical necessity denial decision and additional information on the reconsideration process. When indicated, the ICM will initiate the process for peer-to-peer discussion with a physician, appropriate behavioral health care specialist, or a pharmacist reviewer for a health plan customer under your care.
Contact us at:
Phone: 920-490-6901
Toll-free phone: 888-711-1444, ext. 76901
Fax: 608-327-6300
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If you need to appeal
Arise has a provider appeal process when a claim is denied because:
- Prior authorization is not obtained
- Service/treatment is considered not medically necessary
- Service/treatment is considered experimental, investigational, or unproven
- Complete the entire form
- Include the customer number and claim number
- Attach any additional clinical records
If you're not sure how your inquiry should be handled or where to send it, please contact our Customer Service department at 888-711-1444.
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Member Rights and Responsibilities
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The Member Rights and Responsibilities listed below sets the framework for cooperation among covered persons, practitioners, and the insurer. This information is available to all visitors of our website in the
Customer Handbook
.
As a health plan member, you have the right to:
- Be treated with respect and recognition of dignity and right to privacy.
- Have a candid discussion of appropriate or medically necessary treatment options for his/her conditions, regardless of cost or benefit coverage.
- Participate with practitioners in making decisions about his/her health care.
- Receive information about us, our services, our network of health care practitioners and providers, and the member's rights and responsibilities.
- Voice complaints or appeals about us or the care we provide.
- Make recommendations regarding our member rights and responsibilities policies.
- Receive care according to federal and state mandates
As a health plan member, you have the responsibility to:
- Supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
- Understand the member's health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
- Follow the treatment plan and instructions for care that have been agreed on with the member's practitioners.
- Ask questions about member's diagnosis, his/her treatment plan, and how to best manage his/her health.
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Medical policy guidelines available
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Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for an Arise Health Plan customer under their care.
Medical Polices
can be found on our website by clicking the
Providers
tab and selecting
Medical Policies
. If you receive a determination and would like to review the medical policy guidelines used in that decision, you may contact us.
We also use tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health, to assist in administering health benefits. Medical Policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.
To obtain medical policy guidelines for a specific customer review through Integrated Care Management, submit your request via phone, fax, or in writing to:
Arise Health Plan Integrated Care Management
P.O. Box 11625
Green Bay, WI 54307-1625
Phone: 920-490-6901
Toll-free phone: 888-711-1444
Fax: 920-490-6943
Please include the subject (procedure/service/treatment) for the medical policy in question, along with the customer name and customer number. The policy guidelines are an informational resource, not an authorization, an explanation of benefits, or a contract to provide benefits. Receipt of benefits is subject to satisfaction of all terms and conditions of the customer's contract in effect at the time services are rendered. Medical technology is constantly changing, and we reserve the right to review and update our medical policy guidelines as necessary.
We hope that by providing the specific medical policy guidelines upon request, you may better understand the basis for a decision. Our policy guidelines are based on sound medical and clinical evidence and adopted with the involvement of appropriate medical specialists.
If you have questions or suggestions about medical policy guidelines or want to request a specific medical policy or MCG guideline, email
medical.policies@wpsic.com
or send the request in writing to Arise Health Plan Integrated Care Management, Attention: Medical Policy Editor, at the address above.
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Medical policy updates and review
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The Medical Policy Committee recently met and approved the medical policies due for annual review.
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. We ask that you share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
A technology assessment process is applied to the development of new medical policies and review of existing policies. Policies are reviewed annually, or sooner when there is a significant change reported in the scientific evidence. Published scientific evidence, clinical updates, and professional organization guidelines are reviewed throughout the year, so you can forward a published article at any time.
We value practitioner input regarding the content of our Medical Policies. If you have published scientific literature you would like to have considered or have questions or comments about policies, please forward them to our Medical Policy editor at
medical.policies@wpsic.com
or 800-333-5003, ext. 78993.
Policies that will be reviewed in the upcoming months include the following:
April 2020
- Hip Replacement Surgery
- Knee Replacement Surgery
- Spinal Cord Stimulators
- Capsule Endoscopy
- Reduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia
May 2020
- Back and Nerve Pain Procedures: Radiofrequency Ablation, Facet, and Other Injections
- Back Pain: Sacroiliac and Coccydynia Treatments
- BackPain Procedures: Epidural Injection
- Wearable Cardiac Defibrillator
- Infertility and Recurrent Pregnancy Loss Testing and Treatment
June 2020
- Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
- Glaucoma Surgical Treatments
- Tumor Treating Fields (Alternating Electric Field Therapy)
- Noncovered Services and Procedures
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See what's happening on our social sites:
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©2020 WPS Health Plan, Inc. All rights reserved. JO16840
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