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Doctor's Note
Dear Colleagues,
The articles and guidelines in this newsletter are intended to
enhance our collaboration with you. You'll find tips on using
our
online Provider Portal, information about our Site of Care Program for medication administration, about the prior authorization submission process your staff uses, and about obtaining details of our medical coverage policies.
In addition, we have provided information about, and links to, two national guidelines. These guidelines are for postpartum depression screening and for diabetes screening in people who have schizophrenia or bipolar disorder. The goal is to help your practices take these into consideration in providing the best care to your patients.
Please see our friendly reminder regarding information our customer services staff requires for HIPAA compliance when answering your calls.
Thank you for your continued work with Aspirus Arise Health Plan. If you have any questions, you can contact me at 608-977-8981 or
Michael.Ostrov@wpsic.com.
Best of health,
Michael Ostrov, M.D., M.S.
Chief Medical Officer
Aspirus Arise Health Plan
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Doctor's Note - Population Health
2017 is off to a great start-our health plan (Aspirus Ari
se) is up
and running, Aspirus Complex Care Managers (AKA the Health Resource Team) are actively engaging targeted high-risk and rising-risk patients, and Patient Centered Medical Home (PCMH) coordinators are helping manage chronic disease states for targeted individuals.
All of these efforts are being monitored by the Health Analytics Management (HAM) Team, which is made up of independent experts and representatives from Aspirus Arise, the Aspirus Network, and WPS. The HAM team is focused on building a long-term population health management infrastructure. I serve on the HAM tea
m, which meets monthly, and recently gave a presentation to the leadership of Aspirus. The leadership of Aspirus supports our efforts to further develop and implement initiatives aimed at improving the lives of the patients we serve by working directly with our health plan. Specifically, we are working to improve our ability to identify patients and intervene for those who have chronic illnesses or are at rising risk of having a catastrophic event.
I am excited by the opportunity we have to work together in the future on this collaborative effort with Aspirus Arise. Please let me know if you have any population health management ideas or suggestions that you would like me to bring before the HAM team.
Sincerely,
Renee Smith MD
Interim Executive Director and Chief Medical Officer
Aspirus Network Inc.
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Medical policy guidelines available upon request
Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for a health plan member under their care. If you have received a determination and would like to review the medical policy guidelines used in that decision, you may contact us for a copy.
We also use tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. Medical Policies and MCG 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 member review, submit your request by phone, fax, or in writing to:
Aspirus Arise Medical Management Dept.
P.O. Box 11625
Green Bay, WI 54307-1625
Phone 920-490-6901
Fax 920-490-6943
Please include the subject (procedure/service/treatment) for the particular medical policy guideline in question, along with the patient name and member 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 member'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 general 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 the Health Plan Medical Management Department, Attention: Medical Policy Editor, at the address above.
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Helpful provider information available on our website
The Resources tab at
AspirusArise.com
is a valuable tool. While it includes many topics that may be of interest to you, please note the Provider Resources and My Pharmacy Benefits sections.
Provider Resources
offers information on the following topics:
- iExchange (our web-based prior authorization tool)
- EDI (Electronic Data Interchange)
- Claims
- Authorizations
- Clinical Practice Guidelines
- Medical Policies (Medical and Pharmacy)
- Welcome Providers (Provider Manual, Customer Service Contact Information, Provider Portal User Guides, and Care Management Programs)
- HIPAA Forms
My Pharmacy Benefits
provides our Drug Formulary and information on our Prescription Program.
The Providers tab of the website gives you access to your Provider Portal Account, as well as a convenient link to iExchange.
If you can't find the information you need, please call us at 715-972-8140.
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Bill type is important on corrected claims
When filing corrected claims, be sure to use the appropriate bill type for the services provided in box 4 of the UB form and box 22 of the HCFA form. If you are unsure of the correct bill type to use, please refer to your HIPAA implementation guide for institutional and professional claims.
Include the original claim number supplied on the 835 remit or Provider Remittance Advice (PRA) when submitting a corrected claim. Both the bill type and claim number are important to include whether you submit electronically or on paper, and will prevent delays in processing. Please see our
Corrected Claim Cover Sheet
when refiling via paper.
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Verification necessary over the phone for protection of members' personal health information
Our processes incorporate HIPAA Privacy Guidelines, when applicable. To protect the personal health information (PHI) of our members, our Customer Service Representatives will ask you to provide four unique identifiers before releasing PHI.
These identifiers are:
- 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 city, state, and ZIP code)
- Full phone number (including area code)
To save time, please have this information handy when you call. We appreciate your cooperation with securing our members' information.
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Contact us with authorization denial notice questions
If you have received a denial notice for which you would like to review medical policy guidelines and discuss determination rationale, you may contact the Medical Management team in our Medical Affairs Department by phone, fax, or in writing.
Physicians and other practitioners may speak with the Integrated Care Manager (ICM) who initially reviewed the service to discuss the medical necessity denial decision and additional information reconsideration process. When indicated, the ICM will also initiate the process for peer-to-peer discussion with a physician, appropriate behavioral health specialist, or a pharmacist reviewer for a health plan member under your care.
Contact us at:
Aspirus Arise Medical Management Dept.
P.O. Box 11625
Green Bay, WI 54307-1625
Phone: 920-490-6901
Fax: 920-490-6943
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Provider Portal tips: Patient Inquiry
Our website includes a Provider Portal that allows you to create an on-line account giving you real time, twenty-four hour a day access to:
- Claim status
- Eligibility
- Copayments and deductibles
- Code Combination Simulation Tool
- Secured messaging with Customer Service
In this issue, the focus is on the benefits of using the Patient Inquiry feature. This function enables you to verify the following information without having to place a call to Customer Service:
- Benefits
- Eligibility
- Deductible/Coinsurance/Copay/Accumulation Limits
- Member Address
- Other Insurance Information
- Primary Care Practitioner (if applicable)
You simply need the member's name or member number, and date of birth, from his/her ID card to get started. Click on the patient's name for more detailed subscriber and policy details, as well as recent claim information.
For more information on the Provider Portal, please check out the
Welcome Providers
section of our website under the Resources Section.
If you're not already using our Provider Portal and would like to enroll, please
send an email to
register@wpsic.com
with the following information: Administrator name, email address, tax ID, practice name, and a list of all clinic locations (including addresses).
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Site of Care Program for specific drugs may add convenience for patients
Here are answers to the most commonly asked questions regarding our Site of Care Program:
Q: What is a Site of Care Program?
A: A program that ensures services that can be provided in multiple settings (outpatient hospital, clinic, home) are provided in the most cost-effective setting that is appropriate for a patient. Providers/health care systems often charge different prices based upon the setting in which the service is provided.
Q: How does this relate to drugs?
A: Certain drugs, which are often provided in a doctor's office or outpatient clinic of a hospital, can be safely administered in the home by a nurse (Remicade, immune globulin) or self-administered by a patient (Neulasta, Neupogen).
Q: Is this safe for patients?
A: We have partnered with Diplomat, which has years of experience in home treatments. Diplomat provides patients in-depth training on self-administered drugs. For infusion treatments, they use highly trained health care professionals for their home visits. Diplomat professionals are trained to identify and treat allergic reactions and other adverse events. However, if you have concerns, we permit providers to give initial doses in the office to observe how patients respond.
Q: How do patients get established with Diplomat?
A: As part of the prior authorization approval process, Diplomat contacts your office if a drug is subject to the Site of Care Program. Diplomat asks you for a prescription at that time and then works out the logistics directly with the patient. It's during this process that you can discuss giving initial doses under your observation.
Further questions? Please contact us at 800-332-0899.
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Our Promise:
Make our high-quality health care services cost-effective
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Integrate your health care so that your personal needs and preferences are considered.
Improve the communities we serve.
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