Issue 3 | 2025

Medical policy updates reminder

As indicated in the second issue of our 2025 Provider Network Newsletter, the Medical Policy Committee recently met and approved several new medical policies, as well as those due for annual review. Please take a few moments to review the September 2025 medical policy updates to determine how they apply to your practice–and note the effective date.

Please be sure all doctors, other clinical staff and office staff are aware of these changes before submitting requests for coverage performing services and issuing referrals.

A library of our medical policies can be viewed online at WPS Medical Policy Updates.

2026 WPS Provider Manual coming soon

The WPS Provider Manual is designed and produced for you, our preferred providers, to promote a clear understanding of our policies and procedures; including provider services, prior authorization, claims and eligibility. The next update of the WPS Provider Manual will be released on our website in January 2026.

To access the manuals, click on Resources > Provider Resources > Support and Education > Provider Manual.

WPS’ new Vice President of Health Plan Network Solutions 

Shelley Kubesh is WPS’ new Vice President of Health Plan Network Solutions. She brings nearly two decades of leadership experience in developing and optimizing efficient provider networks, with a proven ability to balance high-quality care, cost-efficiency and provider satisfaction.

Shelley’s passion lies in forging collaborative partnerships, and she is particularly eager to connect with our providers to understand your goals and explore new ways to support your success. We are confident she will build upon the strong relationships WPS has already established.

Prescription drug program updates go into effect Jan. 1  

Information regarding our Prescription Drug Program can be found on our website: wpshealth.com. Specifically, you can access:

• Our Prescription Drug Program Policy, which includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits.

• The Drug Prior Authorization List, which identifies the applicable medications as well as who to contact to initiate the process. 



• Formularies/Preferred Drug Lists, which contain the lists of drugs that are covered under the pharmacy benefit including generic drugs, preferred brand-name drugs, specialty drugs and biosimilars.

New reimbursement policy

Effective January 1, 2026, WPS will implement a new reimbursement policy regarding Preventive and Evaluation & Management (E/M) services billed on the same date.

When a preventive medicine service and an E/M service are billed for the same patient, by the same specialty physician or qualified healthcare professional (QHP), on the same date of service, reimbursement will be as follows: 

• Preventive Medicine Code: Reimbursed at 100% of the contracted rate

• Evaluation & Management (E/M) Code: Reimbursed at 50% of the contracted rate

We encourage providers to use the CES application available within our provider portal to view edit results and rationale that will be applied to specific code combinations. The CES application is available to all contracted providers through our provider portal.

For questions regarding medical coding related to policies, you may contact the Code Governance Committee at codegovernance@wpsic.com. 

For questions regarding the policies outside of medical coding, you may contact Provider.Reimbursement@wpsic.com.

Easily access patient eligibility and benefits through WPS provider portal

Conducting eligibility and insurance verification is necessary. Making the process difficult is not. The WPS web portal simplifies the process so you can focus on giving your patients the care they need.

You can use the Patient Eligibility Link on the WPS provider portal 24 hours a day, seven days a week, to search for:

• Benefits
• Patient network
• Insurance entity name
• Patient information
• Subscriber and policy details
• Other insurance information

With minimal information, you can verify patient eligibility through the Patient Eligibility Search. Enter the minimum search criteria of:



• Subscriber ID + Date of Birth + Eligibility as of Date; or
• Last Name (partial name accepted) + Date of Birth + Eligibility as of Date; or
• First Name (partial name accepted) + Date of Birth + Eligibility as of Date

To see matching records, press the Search button. You can click the Patient name to see more patient details, including:

• Plan effective and termination dates
• Insurance entity
• Network name
• Copay
• Coinsurance
• Deductible
• Out-of-pocket balances

Export the information you need via spreadsheet or PDF file by using the icons in the upper right corner of your screen.

You can find out more about the features of this versatile tool in our Provider Portal User Guide. If you do not currently have a provider account, please complete a Request for Provider Access on our website.

Important Reminder to update to the new WPS logo if you have not already

WPS has updated it logo as of 2024! Please ensure any references to WPS on your website or office materials reflect "WPS A Health Solutions Company" as shown below. You may contact Provider Relations to obtain our logo in the appropriate format for your application (jpg, png, etc) by contacting your Provider Relations contact outlined in our Provider Manual.

Upcoming holiday schedule

While our offices will be closed on the following dates, providers will still have access to benefits, patient information, claim status and other key information via the Provider Portal.

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WPS—A health solutions company | 1717 W. Broadway | Madison, WI | wpshealth.com

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