Health care providers have many demands placed on their time. I've been there and I know how busy you are. That's why I appreciate your time as you review this newsletter.
This month's Summer 2018 newsletter is full of helpful tips, from information on biosimilar drugs to reminders about observation stays and our Medical Policies. Our goal is to provide information and links to assist you in addressing the needs of your patients with Arise Health Plan coverage.
Thank you very much for the great service you provide to your patients, who are our customers, and I hope you enjoy the convenience of and information provided in this newsletter.
Dr. Catherine Inman
Biosimilars to be incorporated in coverage review criteria
We partner with Diplomat to develop and administer appropriate use criteria for specialty drugs in our step therapy programs and prior authorization criteria. These criteria include biosimilars when clinically appropriate. Biosimilars are a relatively new phenomenon, but more will be coming on the market in the near future. The following educational information comes from the
, where additional details concerning biosimilars can be found.
What is a biosimilar product?
A biosimilar is a biological product that is highly similar to and has no clinically meaningful differences from an existing FDA-approved reference product. For example, Renflexis
is a biosimilar to Remicade
is a biosimilar to Neupogen
What is a reference product?
A reference product is the single biological product, already approved by the FDA, against which a proposed biosimilar product is compared. A reference product is approved based on, among other things, a full complement of safety and effectiveness data. A proposed biosimilar product is compared to and evaluated against a reference product to ensure the product is highly similar and has no clinically meaningful differences.
What does it mean to be "highly similar"?
A manufacturer developing a proposed biosimilar demonstrates that its product is highly similar to the reference product by extensively analyzing (i.e., characterizing) the structure and function of both the reference product and the proposed biosimilar. State-of-the-art technology is used to compare characteristics of the products, such as purity, chemical identity, and bioactivity. The manufacturer uses results from these comparative tests, along with other information, to demonstrate that the biosimilar is highly similar to the reference product.
Minor differences between the reference product and the proposed biosimilar product in clinically inactive components are acceptable. For example, these could include minor differences in the stabilizer or buffer compared to what is used in the reference product. Any differences between the proposed biosimilar product and the reference product are carefully evaluated by the FDA to ensure the biosimilar meets the FDA's high approval standards.
As mentioned above, slight differences (i.e., acceptable within-product variations) are expected during the manufacturing process for biological products, regardless of whether the product is a biosimilar or a reference product. For both reference products and biosimilars, lot-to-lot differences (i.e., acceptable within-product differences) are carefully controlled and monitored.
What does it mean to have "no clinically meaningful differences"?
A manufacturer must also demonstrate that its proposed biosimilar product has no clinically meaningful differences from the reference product in terms of safety, purity, and potency (safety and effectiveness). This is generally demonstrated through human pharmacokinetic (exposure) and pharmacodynamic (response) studies, an assessment of clinical immunogenicity, and, if needed, additional clinical studies.
Are biosimilars the same as generic drugs?
Biosimilars and generic drugs are versions of brand-name drugs and may offer more affordable treatment options to patients. Biosimilars and generics are each approved through different abbreviated pathways that avoid duplicating costly clinical trials. Biosimilars are not generics, however, and there are important differences between biosimilars and generic drugs.
For example, the active ingredients of generic drugs are the same as those of brand-name drugs. In addition, the manufacturer of a generic drug must demonstrate that the generic is bioequivalent to the brand-name drug.
By contrast, biosimilar manufacturers must demonstrate that the biosimilar is highly similar to the reference product, except for minor differences in clinically inactive components. Biosimilar manufacturers must also demonstrate that there are no clinically meaningful differences between the biosimilar and the reference product in terms of safety and effectiveness.
|Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review. The policy updates were emailed to providers in April, and we have included them in this issue for your convenience.
to view the revisions to medical policies.
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.
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor at
or 800-333-5003, ext. 78993.
Medical Policies up for review in September 2018
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
or 800-333-5003, ext. 78993.
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.
Policies currently undergoing review with practicing providers and scheduled for Medical Policy Committee discussion in September include:
- Corneal Treatments and Specialized Contact Lenses
- Glaucoma Surgical Treatments
- Microprocessor-Controlled and Myoelectric Limb Prostheses
- Stereotactic Radiotherapy-SRT
- Vision Therapy (Orthoptic Training, Orthoptics, Pleoptics)
- Wearable Cardiac Defibrillators
- Non-Covered Services and Procedures: updates are reviewed on a quarterly basis
Specialty drugs and pharmacies
Knowing which drugs are considered specialty drugs and whether they require prior authorization are important aspects to delivering patient care without delay. The complete list of drugs requiring prior authorization, including specialty drugs, can be found
on our website
Arise Health Plan partners with Diplomat Specialty Pharmacy as its exclusive specialty pharmacy provider. Diplomat provides a high-touch customer experience for your patients that stands alone. They can be reached by phone at 888-515-1357 or via fax at 844-262-8479.
In instances when a specialty pharmacy does not fit with your patient's preferences,
certain specialty drugs can easily be obtained by local,
in-network retail pharmacies, too.
If you have any questions, please call our Pharmacy Team at 800-332-0899.
Affirmative statement on incentives
Utilization Management (UM) decision-making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.
Observation stay review reminder
Observation care has traditionally bridged the gap between outpatient and inpatient care. Most often, observation care is
a shorter hospital stay than inpatient, typically lasting between 24 and 48 hours.
In July 2015, we began
reviewing inpatient stays for appropriate level of care. We will recommend observation care if we conclude it is more appropriate. It is our policy that services be administered in the least costly manner and in a location that is safe and appropriate for the patient.
Inpatient admission or transition to inpatient admission from observation care is generally indicated when a condition, such as an acute myocardial infarction, is diagnosed that requires a longer-term stay or when longer-term treatment or monitoring is needed for a condition. MCG (formerly Milliman Care Guidelines) will be the primary reference when determining appropriate level of care.
Provider portal has a new look
This summer, you will notice a new look and feel to our provider portal. You will find the same valuable information regarding customer eligibility and claim status, but in a format we believe will be easier to navigate. The provider portal may be accessed in the same manner as today with no need to change your password. Should you need help navigating the updated provider portal, please call 888-915-5477.
If you do not currently have a provider account, please register by sending an email to firstname.lastname@example.org that includes your administrator name, email address, tax ID number, and practice name.
Utilization Management follows timeliness standards
As a health plan accredited by the National Committee for Quality Assurance (NCQA), we adhere to the timeliness standards specified by NCQA for review of requested services. The standards include:
- Non-urgent pre-service decisions are determined within 15 calendar days of receipt of the request.
- Urgent pre-service decisions are determined within 72 hours of receipt of the request.
- Urgent concurrent review decisions are determined within 24 hours of receipt of the request.
- Post-service decisions are determined within 30 calendar days of receipt of the request.
These time frames are dependent on the inclusion of necessary clinical information upon receipt of the request. We may request additional medical records if the information submitted to make a determination is not sufficient.
, our online prior authorization tool, is the preferred method to use when submitting prior authorization requests. However, if you must fax a request, please send to
608-327-6300. Written prior authorization requests may be sent to:
Arise Health Plan Prior Authorization
P.O. Box 11625
Green Bay, WI 54307-1625
If we cannot make a decision by our standard deadlines, we notify the affected customer and requesting provider that an extension is necessary. The date by which we expect to make a decision is included in that notice.
We consistently strive to exceed these standards and meet the needs of our customers.
Practitioner rights pertaining to credentialing
Credentialing of practitioners is performed by the Arise Health Plan/WPS Health Insurance Credentialing Department upon initial contracting of practitioners and every three years thereafter. Practitioners undergoing the credentialing process have the following rights:
If you have any questions regarding the contracting process referenced in your Provider Agreement, please contact our Provider Relations Department at 920-490-6903.
- You have the right to review a summary of outside information obtained by the Credentialing Department for the purpose of evaluating your application.
- Requests to review a file shall be made to the Credentialing Manager. The review will take place on site during normal office hours.
- Providers shall not have access to references from other practitioners/health care facilities, recommendations, or peer-review protected information received as part of the credentialing process.
- Providers may receive a copy of only those documents provided by or addressed personally to the provider. A written summary of all other information shall be provided to the practitioner by the Medical Director or his/her designee.
- You will be promptly notified of information that varies significantly from the information you have provided and be given the opportunity to submit updated/additional documentation or corrections to the Credentialing Department. The correction of erroneous information must be done, in writing, within 10 days of being notified of the varying information. The Credentialing Department is not obligated to reveal the source of information if disclosure is prohibited by law.
- You have the right, upon request, to be informed of the status of your application at any time. Requests shall be directed to the Credentialing Manager. The Credentialing Manager shall promptly provide the applicant with information regarding the date of application receipt, the general category of items outstanding, and the target approval date.
- You will be notified of the Credentials Committee decision regarding your application via written letter within 60 calendar days of the Committee's credentialing or recredentialing decision.
Member Rights and Responsibilities
The Member Rights and Responsibilities listed below set the framework for cooperation among covered persons, practitioners, and the insurer. This information is available to all visitors of our website in the Member Handbook.
Member rights as a health plan member
- The right to be treated with respect and recognition of dignity and right to privacy.
- The right to a candid discussion of appropriate or medically necessary treatment options for his/her conditions, regardless of cost or benefit coverage.
- The right to participate with practitioners in making decisions about his/her health care.
- The right to receive information about us, our services, our network of health care practitioners and providers, and the member's rights and responsibilities.
- The right to voice complaints or appeals about us or the care we provide.
- The right to make recommendations regarding our member rights and responsibilities policies.
Member responsibilities as a health plan member
- The responsibility to supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
- The responsibility to understand the member's health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
- The responsibility to follow the treatment plan and instructions for care that have been agreed on with the member's practitioners.
Electronic Data Interchange (EDI) Express Enrollment (E3) FAQs
Did you know
to submitting claims electronically, you can also receive your Provider Remittance Advice and claim payments electronically? We commonly refer to these features as ERA (Electronic Remittance Advice) and EFT (Electronic Funds Transfer).
If you are interested in adding ERA and EFT features to your account, here's what you need to know:
Whether you're submitting directly from your business office or using an approved clearinghouse, you can use our online
EDI Express Enrollment system
Enrollment can be completed in one web session in less than five minutes. The process is completely electronic, and there's no extra paperwork to sign or mail in. Just follow the prompts and enroll in all three transaction types. If you already are submitting claims electronically but would like to add ERA and EFT transitions, use the same link provided above and choose the options you want to add. Options are reflected in the E3 portal as follows:
When using a clearinghouse, an external submitter sometimes referred to as a billing agency or third-party agent, please contact the clearinghouse for the following information prior to enrollment. Don't forget to notify the clearinghouse when your enrollment is complete:
- Trading Partner ID (Submitter ID)
- Clearinghouse Company Name
- Clearinghouse Contact First Name
- Clearinghouse Contact Last Name
- Clearinghouse Contact Job Title
- Clearinghouse Contact Phone Number
- Clearinghouse Extension (if applicable)
- Clearinghouse Contact Email Address
You will receive a confirmation email once the enrollment has been processed. If you are concerned that your enrollment did not go though, please contact our EDI Help Desk at
800-782-2680, option 1.
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