Doctor's Note
Dear Colleagues,
At the onset of this pandemic, who could have predicted its duration and the severity of its impact on our lives and practices? As I write this message, three COVID-19 vaccines have been authorized and are in use, with more likely to come in the future. I know we all are anxiously looking forward to a gradual return to "normal." At WPS, we understand and are grateful for the role that you, as health care providers, play in battling this virus and caring for your patients and our members. You were the heroes pre-pandemic, you are the heroes during the pandemic, and you will continue to be the heroes post-pandemic.
In this issue, we have included updates regarding:
- Our Provider Manual
- Medical Policy guidelines
- Home sleep studies
Thank you for the care you provide to your patients and our customers. If you have any questions, please contact me by email at Jonah.Fox@wpsic.com 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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Provider Manual updated
A revised version of our Provider Manual is now available on our website. The Provider Manual is designed and produced for our participating providers to promote a clear understanding of our policies and procedures, including provider services, prior authorization, claims, and eligibility.
The manual has undergone format changes, the removal of redundant information, and the streamlining of language. It has also been updated to reflect the rebranding to WPS Health Plan, and includes links to correspond to recent changes on the website.
We have added instructions for submitting a prior authorization through Magellan for rehab therapy. We have also included a current customer ID card sample (page 9), and the Claim Payment Policies section now outlines claim resubmission, claim reconsideration, and the provider appeals procedures.
This manual will be revised as appropriate throughout the year. Please refer to the website for the most up-to-date policies and procedures.
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Visit our website to keep up to date with the latest changes related to COVID-19.
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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 to all visitors of our website in the Customer Handbook.
Health plan member 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 member'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 member rights and responsibilities policies.
- The right to receive care according to federal and state mandates.
Health plan member responsibilities:
- The responsibility to supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
- The responsibility to understand the member'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 member's practitioners.
- The responsibility to ask questions about the member’s diagnosis, his/her treatment plan, and how to best manage his/her health.
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Medical policy guidelines available
Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for a WPS Health Plan customer under their care. Medical Polices can be found on our website by clicking the 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.
We also use 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, fax, or in writing to:
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WPS Health Plan Integrated Care Management
P.O. Box 11625
Green Bay, WI 54307-1625
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Toll-free phone: 888-711-1444
Fax: 608-327-6300
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Please include the subject (procedure/service/treatment) for the medical policy in question, along
with the customer 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
WPS Health Plan Integrated Care Management, Attention: Medical Policy Editor, at the address above.
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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 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,
ext. 06984.
Policies that will be reviewed in the upcoming months include the following:
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April 2021
- Acupuncture Therapy
- Cranial Orthotic Device
- Hyperbaric Oxygen Therapy
- Sleep Disorder Testing
- Sleep Disorder Treatment: Positive Airway Pressure Devices and Oral Appliances
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May 2021
- Back Pain: Sacroiliac and Coccydynia Treatments
- Back and Nerve Pain Procedures: Radiofrequency Ablation, Facet, and Other Injections
- Back Pain Procedures: Epidural Injection
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June 2021
- Glaucoma Surgical Treatments
- Infertility and Recurrent Pregnancy Loss Testing and Treatment
- Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
- Tumor Treating Fields (Alternating Electric Field Therapy)
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Contact us with authorization denial notice questions |
If you have questions when you receive a denial notice for services, contact our Integrated Care Management team. You can reach out to the team to review medical policy guidelines and/or discuss
determination rationale.
The Integrated Care Manager (ICM) who initially reviewed the service can discuss the medical necessity
denial decision and provide additional information on the reconsideration process. When indicated, the
ICM will facilitate the process for 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 us at:
Phone: 920-490-6901
Toll-free phone: 888-711-1444, ext. 76901
Fax: 608-327-6300
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Home sleep studies
Currently, providers can fast track their home sleep study via iExchange! There is a new questionnaire providers can complete, while submitting a prior authorization request via iExchange, which can approve the home sleep study instantly. This short series of questions is used to establish the need for a home sleep study. When support for the study is confirmed, iExchange can then auto-approve the request. With the use of our iExchange questionnaire, you can quickly establish whether your patient/our customer can utilize their health benefits for coverage of these home sleep studies and schedule these studies much faster.
For more information about iExchange and its use in home sleep studies, please email us at iExchange@wpsic.com.
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iExchange makes prior authorizations easier |
Tired of using your old fax machine or relying upon the mail to complete your prior authorizations? For
an easier and faster way to submit prior authorizations, use our iExchange online portal.
Using iExchange speeds up the prior authorization process, allowing providers to get the answers they
need faster than ever before. A speedier process means your patients will receive better care.
Want to start using iExchange? Registration is easy. Complete the required information and click
submit. Within 10 business days, your administrator will receive an email with an assigned iExchange
Group ID, User ID, and temporary password for you to access the tool.
Training modules on getting started, adding a submitting provider, and submitting requests can be
If you have any questions, need assistance with registration, or have technical issues, please contact
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Find a Doctor application |
Let our Find a Doctor application assist you with looking for providers within a customer’s current network and/or providers within selected networks.
To access the application, please visit our website and click Find a Doctor. A pop-up box (see below) will appear. Please select Start Your Search under the WPS Health Plan heading to begin your search and follow the prompts. Note: If the subscriber is currently insured with WPS Health Plan, a group number is required.
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Though 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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Date of Closure
Monday, May 31
Monday, July 5
Monday, Sept. 6
Thursday, Nov. 11
Thursday, Nov. 25
Friday, Nov. 26
Friday, Dec. 24
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Holiday (observed)
Memorial Day
Independence Day
Labor Day
Veterans Day
Thanksgiving
Day after Thanksgiving
Christmas Eve
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Need to register for the provider portal? |
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©2021 WPS Health Plan, Inc. All rights reserved. JO19852 |
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