I am pleased to inform you that I have been promoted to Chief Medical Officer. In this new role, I will continue to focus on developing programs and services to help you and your office staff to simply and efficiently get what you need from WPS Health Insurance. Our goal is to provide you with helpful, meaningful data you can use to better care for your patients.
This issue highlights a number of pharmacy programs designed to help with coordination and safety, and, when possible, to decrease patients' out-of-pocket costs. Our Pharmacy Director, Mike Chester, explains these programs and is here to help you and your patients should questions arise.
Other highlights in this issue include:
- Medical Policy updates are provided to be sure you and your staff are kept up to date with the latest technology and coverage topics.
- You can find out more about Diplomat, our specialty pharmacy partner.
Feel free to contact me with any questions.
Best of health,
Michael Ostrov, M.D., M.S.
Medical Director, Network and Quality
Include a cover sheet for corrected claims
Effective Oct. 1, 2016, WPS asks that you include a cover sheet with any corrected claims you submit on paper. This will allow us to process your corrected claims in a more timely manner. Paper corrected claims sent without a cover sheet will be returned to you.
Our website has a sample
Corrected Claim Cover Sheet
on the Provider Forms page that you are welcome to use. You may also use your own version as long as it has provider information, member information, the original claim number, and the items and reasons for the correction.
These can be sent to our updated paper claims address, along with any other claims or claim-related correspondence you have, at:
WPS Health Insurance
P.O. Box 21341
Eagan, MN 55121
Using ERA? Paper PRAs being phased out Sept. 1
Effective Sept. 1, 2016, providers who previously received Electronic Remittance Advice (ERA) will no longer receive the paper Provider Remittance Advice (PRA).
To view your electronic PRAs via the website, please
log in to your Provider Portal account
If you would like to switch from paper to Electronic Funds Transfer (EFT), electronic claim submissions, or have further questions regarding Electronic Remittance Advice (ERA), please contact our Health Insurance EDI department at 1-800-782-2680, option 1,
for details and enrollment forms.
Secure messaging is available
Providers often have questions about secure messaging. Did you know that our Provider Portal allows secure messaging directly with our Customer Service Department? To take advantage of this function, Select
Home from the top menu bar, click on the
Message Center link, and then click on the
New Message link.
The feature allows up to 480 characters, so please clearly state your question, along with the member number, claim number, and any other pertinent information. This enables our Customer Service team to immediately begin researching your issue.
When you use our Message Center, you can expect a response within the next business day. Please note that replies are accessed via the Message Center rather than your email account.
You can access our
Message Center Tip Sheet
for a step-by-step guide.
If you are not currently using our Provider Portal, you may register by email at
. Please include the
administrator name, email address, tax ID, practice name, and a list of all clinic location names and addresses.
What you need to know about Diplomat
Most providers know Diplomat as the nation's largest independent specialty pharmacy--meaning it dispenses expensive drugs that require a high level of member education and monitoring. WPS Health Insurance chose to partner with Diplomat in 2014 because of its long-standing history of providing a superior customer experience. In fact, your patients using specialty drugs provided by Diplomat enjoy, on average, 40 "touches" with Diplomat per year. Those same patients show a medication adherence rate well over 90%, which is phenomenal. These patients are also happy, with a surveyed satisfaction rate of Diplomat services of 99%.
The care Diplomat provides is equally important. Since care is evaluated at least monthly to determine whether members are experiencing issues, a Diplomat pharmacist is promptly engaged to address any clinical issue, such as how to mitigate an adverse reaction. They also initiate outreach to you as the member's provider as the situation dictates.
Diplomat also serves in three other capacities:
1) A division of Diplomat called PA Navigator establishes evidence-based criteria and reviews prior authorization requests for specialty drugs for appropriateness
2) Diplomat Infusion coordinates home infusion services for members requiring such treatments as IVIG (intravenous immunoglobulin) or Remicade (infliximab)
3) Diplomat can supply specialty drugs to provider offices that do not want to purchase and stock these expensive agents on their own; in this scenario, Diplomat ships the drug to your office and bills WPS directly (also known as "white-bagging"); the provider bills any administration fees
Providers can easily initiate a prior authorization request for a specialty drug by contacting Diplomat at 1-888-515-1357. The list of drugs requiring prior authorization is located under the Provider section of our website at
To initiate home infusion services through Diplomat, or to establish a "white-bagging" arrangement, contact Diplomat at 1-866-500-6500.
Contact WPS at 1-920-490-6959 with any other questions regarding Diplomat services.
FluMist® not recommended for 2016-17 flu season
The Centers for Disease Control and Prevention (CDC) recently announced that the live attenuated influenza vaccine (LAIV), best known as nasal spray or by the trade name FluMist Quadrivalent, should not be used during the 2016-2017 influenza season. The CDC's Advisory Committee on Immunization Practices voted to recommend it not be used after data showed poor or relatively low effectiveness of the nasal spray from 2013 through 2016.
Please also see
for information about the use of CDC Vaccine Information Statements (VISs) to provide to your patients. The VISs are available in multiple languages for all vaccines.
The Wisconsin Chronic Disease Program to focus on hypertension
The Wisconsin Chronic Disease Program, sponsored by the Wisconsin Department of Health Services, helps coordinate quality improvement projects for health plans across the state. This year the focus is on improving treatment for people with hypertension, as 30% of adults have some form of hypertension, and 50% of those diagnosed are uncontrolled, according to the National Health and Nutrition Examination Survey (NHANES). Hypertension remains the most common risk factor for heart attack and stroke.
With this in mind, WPS Health Insurance has embarked on a quality improvement project to:
1) Identify members who:
- Have hypertension
- Are not under treatment
- May benefit when we notify providers to potentially initiate treatment
2) Improve adherence of those taking anti-hypertensive medications
3) Improve the number of members whose blood pressure is under control
The hypertension project involves member and provider communications. Additionally, Express Scripts, our pharmacy benefits manager, has been engaged to assist with impacting medication adherence. Express Scripts offers free consultations with pharmacists who are specially trained in hypertension, as well as other tools to help members overcome challenges to taking their medications (e.g., medication alerts).
WPS is pleased to offer this comprehensive hypertension program to support and reinforce what you are doing in your offices.
WPS uses evidence-based medical decision-making tools and processes
The WPS Health Insurance Medical Affairs Department uses both internally developed medical policies and science evidence-based resource products, such as
MCG Health and Hayes, to form the basis for clinical reviews. Both our medical policies and use of resource products are approved by our Medical Policy Committee and Quality Improvement Committee.
Our Medical Policy Committee is composed of clinicians, including practicing providers from the community. The committee meets quarterly to consider
scientific evidence and current practice standards for review and approval of new medical policies and those policies due for annual review. Nationally published and internally developed guidelines are reviewed annually, or more frequently if significant changes in standards of care are identified.
Our Quality Improvement Committee oversees the Medical Policy Committee. Members include clinicians and representatives from multiple departments at WPS, as well as practicing providers from the community.
As previously mentioned, primary evidence-based clinical resources used include:
- MCG Health: Formerly known as Milliman, this company offers a compendium of annually updated, evidence-based guidelines that supports clinical decision-making and care planning for providers and payors. The guidelines are developed through extensive review, analysis, and rating of published clinical literature, as well as expert practitioner reports and protocols.
- Hayes: This independent research organization evaluates and provides evidence-based ratings on a wide range of medical technologies, procedures, devices, pharmaceuticals, and tests to determine the impact on patient safety and health outcomes.
Additional reference sources include, but are not limited to:
- BlueCross BlueShield Technology Evaluation Center
- Clinical Guidelines posted through the National Guideline Clearinghouse (NGC), an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health & Human Services
- Government agencies and regulatory bodies
- National Comprehensive Cancer Network (NCCN)
- National Institute for Health Care Excellence (NICE)
- Specialty society guidelines and standards
- The Cochrane Library
- The U.S. Preventive Services Task Force (USPSTF)
- Washington State Health Care Authority Health Technology Assessment
Internally developed medical policies are available on the
specific patient-related criteria inquiries, contact WPS Medical Affairs at 1-800-333-5003 with the applicable patient name and member number, along with the procedure, service, or treatment in question. If you have questions or comments regarding evidence development or general content of WPS medical policies, contact us at
Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review.
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.
Reminder: Genetic Testing is mentioned in multiple medical policies and always requires prior authorization. To ensure your request is addressed in a timely manner, please provide documentation directly from the ordering provider.
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email at
or call 1-800-333-5003 ext. 64133.
Update on colorectal cancer (CRC) screening
On June 20, 2016, our Medical Directors approved changes to Colorectal Cancer Screening (CRC screening) indications and coverage. These changes were based, in part, on the final United States Preventive Services Task Force (USPSTF) recommendations published in June. USPSTF recommendations dictate Affordable Care Act (ACA) plan coverage of preventive services. A decision was made to follow the recommendations for our other plans as well.
The USPSTF identified low rates of CRC screening as a major public health problem. Early treatment of colorectal cancer can save lives. USPSTF expanded its list of acceptable CRC screening tests in the hopes of improving screening rates.
CRC screening coverage (without prior authorization) will include:
- Traditional (optical) colonoscopy (continued coverage)
- Screening CT colonoscopy (expanded coverage)
- FIT and other stool-based occult blood tests (continued coverage)
- Cologuard DNA test on stool (newly covered)
- Epi-Pro Colon DNA blood test (newly covered)
When is prior authorization needed?
also known as pre-service authorization, pre-authorization, and pre-certification
, is required for a variety
of health services. Please refer to the
Prior Authorization List
, which is updated regularly on our website. Helpful tips about filing prior authorization requests may be found in our
Prior Authorization Tip Sheet
The majority of updates for July 2016 were improved organization, clarifications within service categories requiring prior authorization, and updates of the Medical Policy references.
- Acupuncture was deleted as routinely requiring prior authorization. For many member certificates, acupuncture is not a covered benefit. Please contact Customer Service to verify benefits. If the member's certificate does include coverage for acupuncture, prior authorization is required.
- Prior authorization for intensive outpatient behavioral health treatments is not required. However, records are reviewed for continued services. Check with Customer Service regarding when records are needed.
- Durable Medical Equipment (DME): The list of specific DME needing prior authorization has not changed. The dollar cap for DME rental and purchase was changed to reflect the most common member certificate/plan language with the caveat that the individual member plan dollar amounts for prior authorization prevail: "Prior authorization rental above $750 per month or purchase above $1,000 threshold (or lower if required per member health plan)."
- Infertility services and treatments: Please contact Customer Service to verify benefits and limitations.
WPS will review a prior authorization request if it is submitted when a member or provider is unclear if a service will be covered. This may include new and emerging technology and procedures that
may be a certificate exclusion or benefit since medical language is complicated and many procedures sound alike. When in doubt, prior authorize. We make determinations based on the specific service that is requested and not solely on a service billing code. The member maintains the right for a review determination and an appeal to that determination prior to services rendered.
Customer Service may be reached by calling 1-800-765-4977 or using the Message Center in our Provider Portal.
In our Summer issue, we incorrectly stated the phone number for Stacy Willems, our new Provider Relations contact for the north-central region of Wisconsin. Her correct phone number is 1-608-977-6697. We apologize for the error.
WPS Health Insurance | 1717 W. Broadway | Madison, WI |
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