The latest news for you

Summer 2022

Doctor's Note

Dear Colleagues,

With dashed hopes of a pandemic-free summer, there are still a few positive takeaways to focus on as we move into the next phase of this pandemic. For example, while cases are rising again, this wave is nowhere near what we saw with the Omicron surge earlier this year, even accounting for at-home testing. With available vaccines, testing, and enhanced treatment options, including Paxlovid, we are in a different place with this virus than we were before. Though the United States recently surpassed one million COVID deaths, a number that’s tough to grapple with, people are surviving today that may not have earlier in the course of the pandemic. This is in part due to the diagnostics, vaccines, and therapeutics mentioned above, but it is also due to the many sacrifices that health care providers continue to make for their patients and communities.

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,

Jonah Fox, M.D., M.H.A.

Medical Director

Pharmacy update:

early medication refills

Due to COVID-19, WPS had changed its policy regarding refill-too-soon rejections. We had been allowing pharmacies to override those rejections and fill up to a three-month supply of medications for our members without having to contact WPS or Express Scripts.

With the gradual return to pre-COVID routines, as of April 1, 2022, pharmacies can no longer bypass the refill-too-soon rejection at the point of sale without contacting WPS Health Plan. If you have any questions regarding this policy change, please call the Customer Service number listed on the customer’s ID card.

3D rendering for CT scan, MRI, ultrasound, and

other imagery

The process of 3D rendering creates a two-dimensional image that conveys a three-dimensional relationship of objects. For these services, WPS requires a prior authorization. While certain imaging (e.g., ultrasounds) may not require a prior approval, the 3D rendering of the image does require a review. Other imaging studies (e.g., MRI, CT scan) that require a prior approval will still need to be reviewed. WPS partners with National Imaging Associates (NIA)/Magellan to review certain high-technological imaging studies, but all requests for 3D rendering will be completed by WPS Health Plan. Please fax these requests for 3D rendering to WPS at 608-226-4777.

You can find our 3D rendering policy under Medical Policies on our website. If you have any questions, please call the Customer Service number on the customer’s ID card.

New policy for skin and soft tissue substitutes

WPS has recently developed a new medical policy for skin and soft tissue substitutes. The policy, which will be effective Sept. 1, 2022, addresses:

Tissue-engineered skin substitutes for diabetic and venous stasis ulcers
Allograft-related skin and soft tissue substitutes for other indications, such as burns, surgical postoperative wounds, and other acute or chronic wounds
Skin substitutes used ONLY for breast reconstruction surgery, provided the surgery is not cosmetic

For more information, please see the WPS Health Plan Medical Policy updates for June 2022.

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 Bulletins 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 under review include:

July 2022 (effective Dec. 1, 2022)

Capsule Endoscopy
Cell-Free Fetal DNA Testing
Cochlear Implants, BAHA, Auditory Brainstem Implants, and Other Hearing Assistive Devices
Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment
Septoplasty and Rhinoplasty
Surgical Removal of Redundant Skin and Face/Neck Lift Procedures

August 2022 (effective Dec. 1, 2022)

Reduction Mammoplasty
Urine Drug/Alcohol Screening and Testing
Microprocessor Controlled and Myoelectric Limb Prosthesis
Pneumatic Compression Devices
Wearable Cardiac Defibrillator

September 2022 (effective March 1, 2023)

Non-Covered Services and Procedures-services section (not genetics/DME)

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.

Need to register for the provider portal?

Are you getting the most out of your billing and accounting systems?

WPS EDI trading partners enjoy over a 98% success rate with the exchange of their real-time transactions. You can use WPS EDI for:

Electronic claim submissions
Electronic remittance advice
Real-time and batch eligibility status and response
Real-time and batch claim status and response

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. Through 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
Need 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 EDI Help Desk at 800-782-2680, Monday-Friday, 8 a.m.-4:30 p.m. CT.

Keeping your practice data and demographic information

accurate is vital

Whether shopping for health coverage or using a current health plan, our customers and your patients need to know whether their preferred providers are in-network.

That’s why it’s vital that the practice data you provide us is up to date. Plus, it’s important to referring providers and for compliance with federal guidelines, including the No Surprises Act.

Updating your practice data and demographic information is easy.

Start by periodically reviewing our online provider directory, Find A Doctor, to verify the information is correct. If you find an error, notify WPS Health Plan using one of the following methods:

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.
Facility Data Sheet: Allows you to add, terminate, or change information specific to facilities, including clinic physical location updates (opening, closing, relocating, etc.).
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 GBNetworkDevelopmentDept@wpsic.com.

Thank you for helping us keep your information up to date. By doing so, you’re helping not only us, but our customers and referring physicians.

Tips for completing a practitioner or facility datasheet

Use the most current form on the website.
Complete all the appropriate sections of the form.
For the Practitioner Datasheet, be sure to enable CAQH access for WPS Health Plan when supplying a CAQH number.
For the Facility Datasheet, make sure to include a copy of the W-9 when adding or updating a facility.

Case Managers can make a difference for your patients

WPS designed its Case Management to empower our customers. Through Case Management, customers can learn about their conditions, allowing them to help manage their own symptoms, control health care costs, and improve their health.

Registered Nurse Case Managers help customers achieve these goals by:

Coordinating health care between providers
Providing education regarding their health care needs and concerns, improving health care literacy
Supporting and advocating for improved health care experiences and outcomes
Locating available community resources
Explaining their health insurance benefits
Assisting them to become better health care consumers

Our RN Case Managers work one-on-one with your patients, treating each person as an individual with unique needs and challenges. Through confidential conversations, they get to know your patients and assist each one to overcome challenges affecting their health management and care.

Here’s one recent example. One of our Case Managers reached out to a new customer who had Crohn’s disease and had questions about his medication. During their conversation, the Case Manager found out he had stopped receiving his drug infusions because he was concerned about cost and missing work.

The Case Manager reviewed the customer’s health history and determined he had not received his infusion for more than five months. By not taking his medication, he was increasing the risk of complications such as diarrhea, bleeding, and cramping. In turn, that could have generated higher costs due to urgent care or emergency room visits and treatments of further complications.

The RN Case Manager contacted an in-network infusion provider and helped set up an appointment. The customer received his infusion one week later!

Coming to a new health plan can be confusing, especially for customers who need specialty care and are unsure about their options. Case Management helps them find providers, coordinate care, and ensure the proposed treatment is covered and appropriate under their health plan.

Our Case Management team is here and ready to help your patients. If you have a patient who you feel might benefit from Case Management Services, please contact Medical Management at 800-333-5003 and ask to speak with a Case Manager, or email WPSHI.Case.Management@wpsic.com.

Coordination of care between behavioral health and PCPs

When providers coordinate care, patients benefit. Coordination of care improves treatment planning and helps ensure appropriate diagnosis, treatment, and referral. It’s an essential part of the process for primary care practitioners (PCPs), not just with medical specialists, but also with behavioral health practitioners.

All practitioners should obtain the appropriate permission from customers to coordinate care among behavioral health and other health care practitioners at the time treatment begins.

We expect all health care practitioners to have a mechanism in place to:

Discuss with the customer the importance of communicating with other treating practitioners
Obtain a signed release from the customer and file a copy in the medical record
Document in the medical record if the customer refuses to sign a release
Document in the medical record if you request a consultation
If you made a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner
Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
Diagnosis
Treatment plan
Referrals
Psychopharmacological medication (as applicable)

With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.

WPS partners with Hearing Care Solutions

WPS Health Plan recognizes the importance of hearing care and the impacts of hearing loss on the overall quality of life, as well as the implications of having multiple diseases or conditions when hearing loss is one of them. That is why WPS Health Plan has partnered with Hearing Care Solutions. This new partnership offers customers free hearing exams and discounted rates for hearing aids. Customers who choose a Hearing Care Solutions provider will have access to this additional benefit. Those who choose a WPS contracted provider will continue to have access to the standard in-network benefits and pricing available through the network. To learn more about this new partnership, please contact Hearing Care Solutions at 303-407-6813 or visit https://www.hearingcaresolutions.com.

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.