Doctor's Note
Dear Colleagues,
With COVID-19 booster shots authorized, children ages 5–11 eligible for vaccination, and the domestic outlook having improved significantly between September and early November of 2021, many Americans were beginning to feel a small amount of much-needed relief with respect to the pandemic. This improved sentiment has been tempered as of late, though. As I write this article, cases are once again rising across the country. It is also important to note, especially in our increasingly interconnected world, that Europe and Central Asia have seen a significant increase in cases and deaths as of late. Additionally, the global community is now following the Omicron variant for any potential impact it may have on diagnostics, therapeutics, and vaccines.
On a brighter note, Merck and Pfizer have both released promising news on the fight against COVID-19 with announcements that their experimental COVID-19 pills significantly cut the chance of hospitalization or death for adults at risk of severe disease. While such treatment options will, without question, positively impact the course of the pandemic, they won’t single-handedly eliminate it. COVID-19 antiviral pills are both exciting and an important part of the toolbox, but they should be viewed as a companion to vaccination, not a substitute.
Thank you for the care you provide to your patients and our customers. If you have any questions, please contact me by email at [email protected] or by phone at 608-977-8038.
Sincerely,
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Jonah Fox, M.D., M.H.A.
Medical Director
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News regarding our ASO launch
Last fall, we shared news of an expansion of our administrative services only (ASO) service line for 2022. Customers under ASO employer groups will be enrolled as WPS customers with ID cards that specify WPS Administrative Services Only.
Please keep an eye on your email inbox, where we will send any operations-related updates. You can also find ASO guidelines on the Support and Documentation section of our website under Provider News.
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Prescription Drug Program updates go into effect Jan. 1
You can find information about our Prescription Drug Program on our website. Specifically, you can access:
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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
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The Drug Prior Authorization List, which identifies the applicable medications as well as who to contact to initiate the process
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Formularies/Preferred Drug Lists, which contain the list of drugs that are covered under the pharmacy benefit including generic drugs, brand-name drugs, specialty drugs, and biosimilars
If you would like a copy of this information, please contact our Provider Contact Center at 800-765-4977.
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Formulary/Preferred Drug List changes for Jan. 1, 2022* |
Preferred Drug List Exclusions with Alternatives**
Drug names listed in CAPITALS are BRAND NAME DRUGS. Drug names listed in lowercase are generic drugs.
If you are having trouble viewing the formulary, please click below.
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*May be subject to prior authorization requirements.
**WPS Health Insurance has a pharmacy exception process. Exceptions must be approved in advance for coverage.
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Fast-track home sleep studies using iExchange |
Home sleep studies can now be fast-tracked and approved online. Providers should complete the offered questionnaire while submitting a prior authorization request via iExchange, which can approve the home sleep study instantly! When you complete a short series of questions, iExchange can confirm support for the study and immediately approve the prior authorization request. This allows you to schedule these studies much faster.
For more information about iExchange and its use in home sleep studies, please email us at [email protected].
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Prevent the need for a provider appeal
Did you know most provider appeals are the result of authorization not being obtained before services are rendered?
The best way for you to avoid the need for an appeal is to obtain authorization prior to services being rendered. Our Prior Authorization List can be found on our website. You can also call our Customer Service Department at 800-765-4977 to verify whether services require prior authorization.
If you do need to submit a provider appeal due to lack of a prior authorization, here are a few helpful tips:
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Complete the form in its entirety, including the customer number and claim number
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Submit the form within 60 days of the date of denial listed on your Provider Remittance Advice (PRA)
- Attach any clinical records not previously submitted to be considered in your appeal review
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HEDIS: helping provide patients better care |
We review and evaluate our Quality Improvement (QI) program each year. We use the new QI work plan to help us continually improve the quality of care given by our contracted providers. Our QI program and work plan include both clinical and quality service initiatives.
To evaluate program effectiveness, we use the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is developed and maintained by the National Committee for Quality Assurance (NCQA), a nonprofit health care quality organization.
Why is HEDIS important to physicians? HEDIS measures track a health plan's and physician's ability to manage health outcomes. Generally, strong HEDIS performance reflects enhanced quality of care. With proactive population management, physicians can monitor care to improve quality while reducing costs.
It's not just about the scores. It's about the woman whose pap smear led to early detection and treatment of her cervical cancer. Or the toddler who didn't get whooping cough because he received the appropriate scheduled immunizations. Or the 65-year-old who kept up with screenings that revealed increased cholesterol. As a result, he received appropriate treatment and potentially avoided another heart attack.
We look forward to working with you, our valued providers, during this upcoming HEDIS season. By working together to meet HEDIS benchmarks, we have the best chance of improving our customers' health outcomes and, ultimately, their quality of life. If you are interested in pursuing collaborative quality opportunities with us, please contact our Quality Department at [email protected].
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Is your current provider directory listing up to date? |
Current members, potential members, and providers use our online provider directory, Find A Doctor, to verify whether a provider participates in our provider networks.
To keep the directory accurate, market your services to our members appropriately, and remain compliant with federal guidelines, including the No Surprises Act, we count on you, our preferred providers, to notify us of the following in a timely manner.
- Practitioners joining or leaving your organization
- Changes to practitioner name, licensure, or specialty
- Changes in billing or other contact information
- Changes in service location
- Acquisitions of other medical practices or entities
- Changes in Tax ID number or legal business name
- Changes in ownership
You can notify WPS Health Insurance of provider demographic updates using one of the following methods:
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The Practitioner Data Sheet: Allows you to add a new practitioner to your group, forward changes related to a practitioner’s demographic information or practice location, or notify us of a practitioner’s termination from your group.
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The Facility Data Sheet: This form allows you to add, terminate, or change information specific to facilities, including clinic physical location updates (opening, closing, relocating, etc.).
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The Full File: If you are currently a health system provider that sends us a full file for updates, you may continue to do so. However, time-sensitive updates may be emailed to [email protected].
Your help in providing demographic updates is very much appreciated by us, our customers, and referring physicians.
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2022 Provider Manual coming soon
We produce our Provider Manual so our preferred providers have a clear understanding of our policies and procedures, including provider services, prior authorization, claims, and eligibility. This year, we will be adding information specific to our expanded Administrative Services Only (ASO) service line. Watch for the 2022 Provider Manual, which we will release during the first quarter of 2022.
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Medical Policy updates and review |
The Medical Policy Committee recently met and approved the medical policies due for annual review. View the revised 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.
A technology assessment process is applied to the development of new medical policies and review of existing policies. Policies are reviewed annually or 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 call 800-333-5003, ext. 06984.
Policies that will be reviewed in the upcoming months include the following:
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January 2022
Effective June 1, 2022
- Bariatric surgery
- Biofeedback treatments and devices
- Bone growth stimulators
- Blepharoplasty, blepharoptosis repair, brow lift, and related procedures
- Corneal treatments and specialized contact lenses
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February 2022
Effective June 1, 2022
- Ankle arthroscopy, total
- Artificial disc replacement
- Deep brain stimulation
- Meniscal allograft transplantation
- Neuropsychological testing
- Shoulder replacement
- Telehealth/telemedicine
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March 2022
Effective Sept. 1, 2022
- Noncovered services and procedures—DME and genetics
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Go-to resource for patient eligibility and benefits |
Our provider portal allows you to search benefits, 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, seven 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
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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
You can export information as a spreadsheet or PDF file by using icons in the upper right corner of your screen.
For complete instructions on how to use the functions of our provider portal, please see the Provider Portal User Guide on our website.
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Need to register for the provider portal? |
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Upcoming new 270/271 features |
Over the past year, EDI has been working to add new features that provide additional detail to our trading partners in the 270/271 transaction. We are excited about these upcoming features which include, but are not limited to:
- Dependent information displaying correctly in loop 2100D
- Improved error messaging identifying specific transaction issues
- New Deductible and Catastrophic Cap EB Limit displays
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Transition to TIBCO application nearly complete |
As EDI completes consolidation of our system processing applications, we are moving trading partners to the WPS TIBCO processing system. We have already transitioned nearly 6,000 trading partners and will complete the final phase by the end of the year. All our trading partners will benefit from the improved efficiency and quicker processing times as we centralize and modernize our file processing.
We are working with our trading partners every day to ensure the many components of the transition process are addressed. If you are one of the many trading partners who have transitioned or are in the process of transitioning to TIBCO, EDI appreciates your cooperation. Should you have any questions or concerns, contact the EDI Helpdesk at 800-782-2680, option 1.
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Holiday closures reminder
Though our offices will be closed on the following dates in 2022, providers will still have access to benefits, patient information, claim status, and other key information via the provider portal.
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New Year's Day (observed)
Monday, Jan. 3
Martin Luther King Jr. Day
Monday, Jan. 17
Presidents Day
Monday, Feb. 21
Memorial Day
Monday, May 30
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Independence Day
Monday, July 4
Labor Day
Monday, Sept. 5
Veterans Day
Friday, Nov. 11
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Thanksgiving
Thursday, Nov. 24
Day after Thanksgiving
Friday, Nov. 25
Christmas
Monday, Dec. 26
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WPS Health Insurance | 1717 W. Broadway | Madison, WI | wpshealth.com
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©2021 Wisconsin Physicians Service Insurance Corporation. All rights reserved. JO21635 |
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