Doctor's Note

Dear Colleagues and Office Staff,

This is the fourth issue of our newsletter where we have sought to communicate medical policies more effectively to you. I hope you have noticed these improvements and recognize the thorough work WPS does to stay on the leading edge of evaluating new technologies and treatments.

Not only do we regularly convene our Medical Policy committee which includes a number of your specialist colleagues, but we sit down with individual specialty practices seeking input and incorporating their valuable suggestions. As an example, we recently modified our Stereotactic Radiosurgery policy in relation to an in depth process of this nature.

Finally, we created a tip sheet for a topic many are concerned about: Prior Authorization .

As always, feel free to contact me with any questions.

Michael Ostrov MD MS

Genetics Corner

WPS Health Insurance requires prior authorization for Genetic Testing. We value the clinical information that is submitted from our ordering health care providers. Therefore, clinical documentation must come from the ordering provider and/or associated genetic counselor.
Because order forms direct from the genetic laboratory do not provide sufficient information regarding the ordering provider's clinical assessment, rationale for the specific requested test, or the plan of care, we are unable to accept that as sole documentation to the prior authorization request.

Documentation of the member's clinical history and genetic counseling evaluation will be required for all genetic tests. The documentation must include results of the pertinent family history (family pedigree), communication regarding the genetic risks, evaluation to confirm, diagnose, or exclude specific conditions, and information regarding the specific changes in management that would be made to the current treatment plan based on the findings of the genetic test being requested. The genetic counselor or provider performing the genetic history and evaluation must be free of commercial bias.
Please submit the required documentation through iExchange at  for prompt review of your prior authorization request.

Pain Injection Update

Beginning Jan. 1, 2016, many of our member certificates will have changes in the calendar year limits applied to pain management procedures.
  • Epidural injections, including selective nerve root blocks will be limited to three injections per year regardless of location, type, or level.
  • Facet joint injections/medial branch nerve blocks will be limited to a maximum of four per year regardless of location, type, or level.
  • Neuroablation will be limited to one treatment per year regardless of location.
  • Sacroiliac joint injections are limited to one per year.
Please note that many pain management services are considered experimental/investigational/unproven and therefore not covered.  

Refer to the Non-Covered Services Medical Policy on our website for the list of non-covered services:    

Please contact Customer Service (as listed on your patient's insurance card) to verify your patient's specific coverage and limitations, and provider and facility participation in the health plan. 
Quarterly Medical Policy Updates

The Medical Policy Committee met this quarter 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. Please also 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:  
No password required!
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email or call 1-800-333-5003 ext. 64133. 

Benefits of iExchange

Prior authorization requests should be submitted via iExchange whenever possible. Benefits of iExchange include:

Save paper!
  • Electronic submission
  • Ability to attach documents
Ease of tracking!
  • Assignment of a Request ID number
  • Monitoring the status of the request (i.e. Auto-approval; Pended for review)
  • Communication with our staff through iExchange
Save time!
  • Immediate feedback
  • Alerts when the case has been updated
  • Printable requests/approvals for the provider
If you'd like more information regarding iExchange, please contact us at or contact Jim Sarnosky at (608) 226-4159 or

Deductible on Provider Portal

We often get calls regarding member's deductible. Did you know the Provider Portal provides deductible limits and a deductible accumulator? This enables you to see how much has been applied to a member's account in real time without having to place a call to Customer Service. 

How to find member benefits description (deductibles, copays, coinsurance percentages, out of pocket maximums, etc.)
  1. Select Patient Inquiry from the top menu bar and then click on the Patient Inquiry button
  2. Enter Member Number and click enter
  3. Click on the Member Name
  4. Click Plan Name listed under the 'Subscriber and Policy Details' heading

If you're not already using our Provider Portal, please send an email to with the following information: Administrator name, email address, tax ID, practice name, and a list of all clinic locations (including addresses).

Claims Timely Filing

The number of days to file a claim is counted from the date of service to the date of our receipt of a clean claim. If you receive a letter from WPS or Emdeon indicating claim was not accepted, resubmission is necessary; it refers to an unclean claim and is not considered a received claim. In this scenario, we suggest you address the issue of missing or invalid information and resubmit as soon as possible to meet the timely filing parameters outlined in your agreement with WPS. 
Electronic Data Options

Want to save time, money & paper by filing electronic claims?
Complete our WPS Electronic Data Interchange (EDI) Claims Agreement form at: 
Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) are also available. There is no paperwork involved! All you have to do is complete and submit our online forms and we'll get you set up. These online forms can be found for the following: 

Any questions? Please contact us at:
EDI (Electronic Data Interchange) Department
  • EDI Marketing: Call (toll-free) 1-800-782-2680 Option 4
    For questions about EDI enrollment for claims submission, electronic remittance and electronic funds transfer:
  • EDI Help Desk: Call (toll-free) 1-800-782-2680 Option 2
    For questions about online registration, password resets, how to login, missing files or any other technical concerns:
  • Hours: 7:55 AM - 4:30 PM Monday - Friday (CST)
  • Fax: 608-223-3824
  • Email: 
Thank you for choosing WPS as your trusted health insurance partner!
WPS Health Insurance| 1717 W. Broadway | Madison, WI |
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