Doctor's note

WPS is pleased to announce that our Case Management Team has established a Maternity Program. The goal of the program is to improve health outcomes for both parents and their infants, while providing greater support to our members on their journeys through pregnancy. The program is open to all pregnant members of any WPS health plan which includes Case Management services, and is available at no additional cost. For more information for you and your patients, please call 800-333-5003 or visit wps.health/maternity.

This issue features stories about:

• Our new specialty drug preferred pharmacy
• Updated provider manuals
• Integrated Care Managers and authorization denials
• Online patient eligibility and claims status verification

We appreciate all you do in caring for your patients. If you have any questions, please contact me by email at Kevin.Rak@wpsic.com.

Kevin M. Rak

Medical Director

WPS Health Insurance/WPS Health Plan

Introducing WPS Provider Network News

We are excited to introduce the launch of our new, quarterly provider newsletter—WPS Provider Network News—which we believe will better serve you. We have consolidated our policies and procedures, allowing us to combine the WPS Health Insurance Provider Connection and the WPS Health Plan Provider News. You will still receive important news and information, including policy updates, billing and coding guidance, and much more—but now it will be combined into a single publication. 

With this latest update, we want to remind our providers of the following:

• Disseminate the newsletter to appropriate personnel within your organization
• Make sure we have your correct email address on file and/or add wpsprovidernewsletter@wpsic.com to your safe senders list
• Copies, including archived editions, are available on our website under Provider Resources > Provider News

PLEASE NOTE: WPS Health Insurance and WPS Health Plan are separate business entities. A signed agreement with one does not secure participation with the other.

Specialty drug preferred pharmacy change goes into effect on April 1

WPS relies on preferred vendors to manage specialty drugs for customers, which is why we are pleased to announce our partnership with Accredo^® Specialty Pharmacy as our preferred specialty drug pharmacy. The new partnership begins April 1, 2023. Optum Specialty Pharmacies will no longer be part of the WPS pharmacy network effective that date.

To help ensure a seamless transition, affected customers with active prescriptions (eligible prescriptions with remaining refills) are being systematically transferred from Optum Specialty Pharmacy to Accredo. If customers continue to use Optum after April 1, they will have increased out-of-pocket costs and possible disruptions. Notifications will be sent to all affected customers.

Customers currently filling specialty drugs at a retail network pharmacy can continue using their pharmacy. These customers will also receive a notification letter informing them WPS is moving to Accredo as our preferred specialty drug pharmacy.  

For customers without a current prescription or the prescription has expired, there are a few options to submit a prescription referral which can be submitted right away. 

Electronically

You can use Accredo’s prescriber website MyAccredoPatients.com. Simply register or login and navigate to Send a Referral on the dashboard. Once you log in, you will be routed to iAssist, which is Accredo's electronic referral service. If you are not registered for iAssist, you will be prompted to do so.

Fax

Visit accredo.com and select Prescribers at the top of the page and then Referral Forms. You can choose referral forms by product or therapy name, or by the first letter of the specialty condition. Then, fill in the required prescription and enrollment information and fax it to the number printed on the form.

Phone

You can also contact Accredo at 866-759-1557. Representatives are available 7 a.m.-7 p.m. CT, Monday–Friday. 

We appreciate your support and assistance with this transition. If you have questions about the specialty drug preferred pharmacy change, please contact the WPS Provider Contact Center at 888-711-1444.

2023 Provider Manuals now available

The updated 2023 Provider Manuals are now available on our website. We design our Provider Manuals so you can have a clear understanding of our policies and procedures, including provider services, prior authorization, claims, and eligibility. 

We encourage you to review the manuals in full, as we have made several enhancements and updates, including:

• Linking the Table of Contents so you can easily navigate through the manuals
• Identifying procedural differences between our commercial insurance and WPS Powered by Auxiant ASO plans
• Updating the Drug Prior Authorization and Non-formulary Exceptions section to reflect the new processes

View Provider Manuals below

Question on an authorization denial notice?

Contact us.

Did you receive a denial for an authorization? Our Integrated Care Management team is here to help.

You can speak directly to the Integrated Care Manager who reviewed the service. They will answer your questions, review medical policy guidelines, and/or discuss the reason the authorization was denied. You can also find out more about the reconsideration process.

If necessary, your Integrated Care Manager can arrange a peer-to-peer discussion with a physician, an appropriate behavioral health care specialist, or a pharmacist reviewer for a health plan customer under your care.

Contact our Integrated Care Management team:

Toll-free: 800-333-5003

Fax: 608-226-4777

You don't have to call for patient eligibility and claims status

Do you currently verify a patient’s eligibility or claim status by phone? Did you know you can do this online using electronic transactions—and save time and money by doing so? Talk to your vendor about your system’s capabilities. Your vendor may provide hardware, software, and/or ongoing support for a total office automation or submission of EDI transactions. With EDI, you can:  

• Lower administrative, postage, and handling costs
• Maintain investment in your billing system
• Avoid payment delays or interruptions
• Waste less time on the phone checking eligibility
• Lower operating cost of verifying eligibility
• Receive payments more quickly
• Endure fewer reviews

WPS can be your single point of contact for EDI support that’s accurate, timely, and available through a variety of channels. The EDI Help Desk provides front-line support regarding basic EDI information and troubleshooting. You can reach the EDI Help Desk at 800-782-2680, Monday–Friday, 8 a.m.–4:30 p.m. CT.

Go-to resource for patient eligibility and benefits

To better help you care for our members, our provider portal allows you to search benefits, the patient’s network, insurance entity name, patient information, subscriber and policy details, and other insurance information through the Patient Eligibility link 24 hours a day, 7 days a week. 

To verify patient eligibility, simply click on Patient Eligibility Search and 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

When you press the Search button, matching records are displayed. Click Patient name to see more patient details, including:

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

Information can be exported as a spreadsheet or PDF file by using icons in the upper right corner of your screen.

Need to register for the provider portal?

New and updated reimbursement policies

Check out our reimbursement policies on our website under Resources > Support and Education.

New policy:

• ER Facility Level of Service Review Policy

Recently updated reimbursement policies:

• Modifier Reimbursement Policy
• Multiple Procedure Reduction Policy
• Status B Policy
• Surgical Assist., Co-Surgeons, Surgical Teams

We also encourage providers to use the Claim Edit System (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. If you do not currently have a provider account, please complete a Request for Provider Access on our website.

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.

New WPS telehealth policy coming soon

WPS currently has a temporary telehealth policy put in place related to the COVID-19 pandemic. With the Public Health Emergency set to end on May 11, 2023, WPS will be creating a new telehealth policy. Watch for the new policy which will be available on our website soon!

Medical policy guidelines

Physicians and other practitioners may obtain a copy of the medical policy guidelines used when making medical coverage determinations for a WPS customer under their care. Medical Policies can be found on our website by clicking the Provider Resources tab and selecting Support and Education. If you receive a determination and would like to review the medical policy guidelines used in that decision, you may contact us.  

WPS also uses 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 or fax: 

Toll-free: 800-333-5003

Fax: 608-226-4777

Please include the subject (procedure/service/treatment) of the medical policy in question, along with the customer’s 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.

Medical Policy updates and review

The Medical Policy Committee recently met and approved the medical policies due for annual review. 

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.

The complete library of our medical policies can be found at WPS Health Insurance/Health Plan Policy Updates on our website; no password required.

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. 06984.

Policies that will be reviewed in the upcoming months include:

Valuable forms and documents available on our website

A host of valuable forms and documents are available on our website, wpshealth.com, including the following:

• Corrected Claim Form
• Claims Reconsideration Form
• HIPAA Forms and Documents
• iExchange (electronic prior authorization tool)
• Outpatient Behavioral Health Care Treatment Plans Request Forms
• Prior Authorization Guidelines
• Prior Authorization Request Forms
• Provider Appeal Form
• Provider Directory and Demographic Update Forms (Practitioner and Facility Data Sheets)
• Utilization Management/Quality Management Program and Procedures

Please ensure you are using the most up-to-date version of our forms as use of an outdated form may cause delays in the credentialing, contracting, and/or claims payment processes.

If you are unable to find what you are looking for, contact our Provider Customer Service Center at 800-765-4977.

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 on our website in the Customer Handbook.  

Health plan customer rights:

• The right to be treated with respect and recognition of dignity and the 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 customer'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 customer rights and responsibilities policies.
• The right to receive care according to federal and state mandates.

Health plan customer responsibilities:

• The responsibility to supply information (to the extent possible) that we and our practitioners and providers need to provide care.
• The responsibility to understand the customer'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 upon with the customer's practitioners.
• The responsibility to ask questions about the customer’s diagnosis, his/her/their treatment plan, and how to best manage his/her/their health.

Holiday closures reminder

Even though our offices will be closed for the upcoming holiday, you can still access benefits, patient information, claim status, and other key information via our provider portal. We will release holiday closures for the second half of 2023 in the summer edition of the provider newsletter.

Memorial Day

Monday, May 29

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