The latest news for you

Fall 2022

In this issue

In the latest issue of Provider News, you'll find helpful information to assist you in addressing the needs of your patients who have chosen WPS Health Plan coverage.

There are articles on:

WPS Health Plan leaving the Health Insurance Marketplace^®
The Federal Price Transparency and Consolidated Appropriations Act
The Welldoc diabetes management app
Population health management programs for diabetes, respiratory health, and opioid use
Flu vaccinations
And more

We have a deep appreciation for the work that you do, and we all thank you very much for the great service you provide to our customers.

WPS Health Plan exiting the Health Insurance Marketplace^®

WPS Health Plan has notified the Centers for Medicare & Medicaid Services (CMS) that it will not be participating in the Health Insurance Marketplace for 2023. WPS has offered individual policies both on and off the Health Insurance Marketplace, but low enrollment and a highly competitive price-driven market have resulted in the need to cease offering this product.

Customers will be notified of this change and will be auto-enrolled by CMS into a plan with another carrier prior to Nov. 1.

WPS Health Plan will continue to offer individual coverage to customers who purchased outside of the Marketplace. These customers will be enrolled in the WPS Health Plan Select Plus network for 2023. Providers will not need to make changes to their Provider Agreements as a result of this change as our contracts include both Select and Select Plus networks.

If you have any questions regarding this change, please contact your Contract Manager or WPS Health Plan Sales at 800-332-1398, Monday through Friday, 8 a.m. to 4:30 p.m.

The Federal Price Transparency and Consolidated Appropriations Act and you

The Federal Price Transparency and Consolidated Appropriations Act increases transparency by removing contract confidentiality provisions, often referred to as “gag clauses.”

Group health plans and insurers may not enter into any agreement with health care providers, networks, associations of providers, third-party administrators (TPAs), or others who offer access to a network of providers, if that contract restricts the plan from disclosing provider-specific cost or quality-of-care information or data, through a consumer engagement tool or any other means, to:

Referring providers
The plan sponsor, participants, or beneficiaries
Individuals eligible to become participants or beneficiaries of the plan

Your agreement with WPS Health Plan may include a confidentiality provision that lists types of information that neither party may disclose. Additionally, your agreement includes a provision that the parties will comply with applicable law, regardless of any language in the agreement to the contrary. The Consolidated Appropriations Act constitutes a requirement by law, and nothing in the agreement with WPS Health Plan will be interpreted to supersede or conflict with the requirements of the Consolidated Appropriations Act.

To remain in compliance and improve transparency, WPS Health Plan will omit gag clauses from new agreements and will continue to remove gag clauses from existing agreements as they are renewed.

Introducing the Welldoc app for diabetes management

Welldoc is a unique app designed to empower patients and streamline chronic care.

WPS Health Plan is excited to announce that all fully insured health plans have access to Welldoc technology to help customers manage diabetes—all at no cost to the customer.

Welldoc is more than an app. It's a digital health platform that acts as a personal diabetes

coach, right from a smartphone or computer. It’s easy to use and gives real-time feedback on

how to better self-manage diabetes.

With Welldoc, customers have the ability to:

Sync smart devices, including fitness trackers and blood glucose meters, to track the most important vitals
Get personalized feedback, digital coaching, insights, and education to help make better health decisions
Understand how diet affects health with food features like the Meal Planner and Restaurant Helper
Use smart medication reminders to keep track of all medications and never miss a dose
See daily and weekly trends and securely share with care teams to understand patterns and how to address them

Let your patients know about how Welldoc can help them better manage their health! Please share the website welldoc.com/wps with them so they can learn more and download the Welldoc app.

Take advantage of WPS population health management programs for diabetes and respiratory health conditions

WPS Health Plan has population health management programs for Diabetes and Comorbidity and Respiratory health conditions. These programs provide customers with education, resources, and assistance such as:

Helping customers understand the importance of following up with their primary care practitioners or specialists after emergency room, urgent care, or inpatient visits related to diabetic and comorbidity or respiratory health conditions.
Helping customers learn how to better manage their medical conditions by:
Taking their prescribed medications correctly
Creating a personalized action plan to discuss with their providers
Eliminating or reducing environmental triggers
Incorporating active, healthy lifestyles
Providing customers with smoking cessation support and education regarding available community and online resources as well as no-cost smoking cessation products available through their health plans
Providing education to customers to help ensure they have the supplies and diabetes-related checkups they need to manage their diabetes properly

If you have a patient you feel would benefit from the population health management programs for Diabetes and Comorbidity or Respiratory health conditions, please call 800-333-5003. Our Population Health Specialists and Registered Nurse Case Managers are eager to help.

WPS offers population health program for opioid use

According to the Centers for Disease Control and Prevention, prescription opioids are often prescribed following surgery or injury to treat moderate to severe pain. In recent years, there has been an increase in the use of prescription opioids for the treatment of chronic pain, despite serious risks and lack of evidence about their long-term effectiveness.

Opioid prescription drugs used to treat pain include oxycodone, hydrocodone, codeine, morphine, and others. While prescription opioids are generally safe when taken for a short time as prescribed by a doctor, they can be misused by taking them in a different way or in a larger dose than prescribed. Regular use can lead to dependence, overdose incidents, and death.

WPS has Population Health Specialists and Registered Nurse Case Managers who work together to coordinate programs for our customers' care.

When patients join the program, a nurse will reach out to help them:

Understand the instructions on properly following the prescription
Answer any questions they may have
Connect patients with community-based resources, if necessary

If you have a patient who wants to participate in this Population Health Management Program, please call 800-333-5003.

Urge your patients to get annual influenza vaccination

WPS Health Plan covers all preventive immunizations at 100%, including the influenza vaccination. If an office visit is associated with the vaccination and that office visit is billed utilizing a primary diagnosis showing immunization or vaccination, then that office visit is considered preventive and is covered at 100% in-network. Additionally, WPS Health Plan covers all preventive immunizations administered at an in-network pharmacy at 100% as well, including the administration charge that is typically billed in conjunction with the charge for the vaccination itself.

With your help, better outcomes can be achieved when you are proactive about the flu vaccine. We encourage you to discuss the importance of the flu vaccine with your patients, as well as where they can obtain it.

Accurate demographics help keep you connected

WPS Health Plan wants to ensure our providers and customers have the correct information they need when seeking medical care. Submitting the Practitioner Data Sheet allows us to accurately reflect your information in our provider directory. The WPS Practitioner Data Sheet is a fillable PDF form used to notify WPS Health Plan of any practitioner demographic updates within your organization.

There are many important aspects of the Practitioner Data Sheet that help us keep our directory up to date, including adding new practitioner(s) and/or location(s), as well as changes to:

Practitioner name
Provider licensure
Practitioner specialty
Address(es) or office location(s)
Billing address
Telephone number(s)

Perhaps the most overlooked aspect is providing termination information when a practitioner leaves the participating provider network. Not only is the directory updated to reflect the practitioner is no longer with your organization, but it also allows us to notify customers of their rights to continuity of care.

We count on you to submit your additions, changes, or terminations. This leads to accurate data, which helps connect you with other providers and our customers.

Please access the Practitioner Data Sheet on our website under Provider Resources/Forms and Documents. Recent revisions to the form include additional fields related to telehealth services and hospital affiliations.

Save time on patient eligibility and claims status with EDI

Do you currently verify patient eligibility and/or claim status by phone? Did you know you could do this online by using electronic transactions AND save time and money by doing so? Talk to your vendor about your system’s capabilities. They may provide hardware, software, and/or ongoing support for 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 costs to verify eligibility
Receive payments more quickly
Endure fewer reviews

WPS Health Plan 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, or email [email protected].

Provider portal tips: claims search

Did you know that our provider portal has information and tools to save you time? One such tool is the Claims Search feature. The Claims Search section of the provider portal allows providers to search for claims and view claim details and corresponding Provider Remittance Advice (PRA).

To search a claim, use the Claims Search button under Quick Links. On the Claims Summary page, you can search by claim time frames, patient name, and account number. You can also search by check/EFT number by clicking the Advanced Search button.

When your search is complete you will see the following information for the claim(s) you requested:

Claim Number
Provider Name
Customer ID
Customer Name
Date of Birth

Date of Service
Total Billed
Status
Check/EFT Number

To see additional claims details, including patient information, PRA, and customer eligibility/benefits, click on the Claim Number.

For complete instructions on how to take advantage of this and other time-saving tools, please see the Provider Portal User Guide on our website.

Need to register for the provider portal?

Terminology and time frame rundown: claims reconsiderations, provider appeals, and corrected claims

What is a claims reconsideration?

A claims reconsideration is a formal review of a previous claim reimbursement or coding decision.

When should you submit a Claims Reconsideration Request Form?

You should submit a Claims Reconsideration Request Form when you believe a claim was paid incorrectly. Situations appropriate for use of the Claims Reconsideration Request Form include the following:

The reimbursement amount is different than what the provider expected
You have proof of timely filing of a claim denied for being late
You have a dispute regarding Coordination of Benefits (COB) information

What is the time frame for submission?

You have 180 days from the original processed date to submit a claims reconsideration request.

What is a provider appeal?

A provider appeal is a written request to change an adverse post-service claim decision based upon noncompliance with prior authorization requirements or a determination that the services rendered were not medically necessary or were experimental, investigational, or unproven.

When should you submit a Provider Appeals Form?

You should submit a Provider Appeals Form when you wish to challenge a post-service claim denial for one of the following reasons:

Services were denied as not medically necessary or experimental, investigational, or unproven, but you believe that the determination is incorrect and can provide clinical documentation or scientific literature to support your position
Services were denied for lack of prior authorization, but you have an approved authorization number
Services were denied for lack of prior authorization, but you believe the prior authorization requirement should be waived due to extenuating circumstances; please note that even when the prior authorization requirement is waived due to extenuating circumstances, services will still be subject to a medical necessity review and clinical documentation should be submitted with the provider appeal

What is the time frame for submission?

You have 60 days from the date of post-service claim denial to submit a provider appeal.

What is a corrected claim?

A corrected claim is a replacement and/or correction of a previously submitted claim that included incorrect information. A corrected claim is not an inquiry or appeal.

How should you submit a Corrected Claims Form?

We encourage providers to submit new and corrected claims electronically. When submitting a corrected claim electronically, use the appropriate Claim Frequency Type code to ensure your claim is noted as a correction. No additional form is required.

If you are unable to submit your corrected claim electronically and wish to submit via paper, the Corrected Claims Form is required. Paper submissions are required when the previously submitted claim includes a revision to coding, service dates, billed amounts, or customer information.

What is the time frame for submission?

You have 180 days from the original processed date to submit a corrected claim.

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.

Medical Policy updates and review

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

Click here 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.

The complete library of our medical policies can be found at WPS Health Plan Coverage 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 [email protected] or 800-333-5003, ext. 06984.

Policies under review include:

October 2022 (effective March 1, 2023)

Negative Pressure Wound Therapy
Otoplasty and Reconstruction of External Ear
Varicose Vein Treatments
Gastrointestinal (GI) Pathogen Testing Using Multiplex Polymerase Chain Reaction (mPCR)
Fecal Microbiota Transplant

November 2022 (effective March 1, 2023)

Autologous Chondrocyte Implantation (ACI) and Matrix-Induced Autologous Chondrocyte Implantation (MACI)
Gender Dysphoria Treatment
Osteoarticular Transfer System (OATS) Procedure and Mosaicplasty
Spinal Cord Stimulators
Hip Replacement Surgery
Knee Replacement Surgery

December 2022 (effective Jan. 1, 2023)

New-to-Market Medications and New-to-Market Medication List

Holiday closures reminder

Even though our offices will be closed for these upcoming holidays, you can still access benefits, patient information, claim status, and other key information via our provider portal.