In this issue, you'll find a lot of helpful information plus tips to save you time. Please take a few minutes to review this newsletter.
There are articles on how to properly submit claims, how our RN Case Managers can help your patients, why coordination of care is important, and much more. My hope is that the information and links contained here will assist you in addressing the needs of your patients who have chosen WPS Health Insurance coverage.
I have a deep appreciation for the work that you do, and we all thank you very much for the great service you provide to our customers. I hope you find the information provided in this newsletter beneficial to your practice.
Dr. Catherine Inman
Resubmission vs. corrected claims
Sometimes a claim is submitted but cannot be processed/entered into our system because it is not a "clean claim." A clean claim is defined as a request for payment for covered services that is accurate, complete, and in the manner and format prescribed by the insurer, and has no substantial issue regarding the insurer's responsibility for payment, including, but not limited to, subrogation or coordination of benefit issues.
Clean claims must be submitted using:
- Current HIPAA standard professional or institutional claim formats for electronic claims, as applicable; or
- Current UB-04 and CMS 1500 forms (or any successor forms) for paper claims; and accepted coding standards
If a claim does not meet the criteria as a clean claim, you will receive notice. That notice will consist of a 277CA electronic transaction for electronically submitted claims. If the claim submission was on paper, you'll receive a letter. When resubmitting a claim, please resubmit as a new claim using submission type 1. While no Corrected Claim Form
is required, it is essential the resubmitted claim meets the clean claim criteria listed above.
claim needs to be resubmitted because there was an error on the original claim that needs correction. When resubmitting electronically, be sure to use the correct Claim Frequency Code (billing code) of 7 for a replacement/correction or 8 to void a prior claim. Don't forget to enter the original claim number in the 2300 loop in the REF*F8*. If submitting on paper
Corrected Claim Form
must accompany your resubmission.
Please complete the form in its entirety.
The easiest way to remember whether a Corrected Claim Form is required is that claims returned to you with no claim number don't need the form when resubmitted. Claims assigned a claim number on a Provider Remittance Advice (PRA) or Explanation of Benefits (EOB) do require the Corrected Claim Form when they are resubmitted.
Focus on flu vaccine
The season is upon us: fall, football, and flu vaccine. The influenza vaccine rate in Wisconsin for the 2016-17 flu season was 42.6%, which is below the national average of 47.5%. When providers are proactive and prescriptive about the vaccine, better results can be reached. If you're not already doing so, adopting a "While you're here, let's give you your flu vaccine" approach may help.
The time is now, and flu vaccines are covered under customer health plans!
Our RN Case Managers can make a difference for your patients
Our RN Case Managers are here to help our mutual customers by:
- Coordinating health care between providers
- Providing education regarding their health care needs and concerns
- 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 is an example of how one of our Case Managers made a difference for a patient like yours. A health plan customer with a history of transplant was trying to manage chronic low back pain. The customer did not want to take pain medications due to the transplant history, and was getting more and more frustrated when unable to find instant relief after seeing multiple in- and out-of-network providers. The customer was searching online for experimental treatments and cures, but did not understand the risks or potential financial impact of trying experimental treatments.
Our RN Case Manager reached out to this customer and took the time to get to know the person's concerns. Through these conversations, the CM was able to help the customer understand the risks of experimental treatments, as well as understand the importance of communicating concerns and questions to a provider and working with the provider to develop a treatment plan to meet the person's needs. Our Case Manager built a trusting relationship with this customer and assisted the customer in finding an in-network orthopedic provider who delivered a successful outcome.
We are here and ready to help your patients. If you have a patient 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.
Notify us of inpatient hospital admissions
We require notification of a customer's urgent/emergent hospital admission
within 48 hours of admission
. Immediate notification is best to help facilitate timely medical necessity reviews, inpatient stay authorizations, and claims processing.
When notification is not received, there is no medical necessity review completed and no authorization in place, which results in denied claims. We want to work with hospitals to ensure processes on both sides can be completed efficiently.
The most convenient and efficient way to notify us of a customer's inpatient admission is online through iExchange. This online portal lets you send the information directly to us 24 hours a day, seven days a week. You can also attach medical documentation for the required medical necessity review through iExchange, helping with quicker turnaround times for reviews and authorizations.
Please visit our website or email us at iExchange@wpsic.com
to register for iExchange or for additional information on how to get started using this convenient tool.
Notification of inpatient admissions can also be done by phone at 800-333-5003 or by fax at 608-226-4711.
Use iExchange to complete prior authorization requests faster
WPS Health Insurance offers a FREE online service to speed up your prior authorization requests. It's called iExchange. This tool allows you to electronically submit prior authorization requests for inpatient and outpatient services directly to us 24 hours a day, seven days a week. There are many benefits to using iExchange, such as:
- Automatic approval of specific requests
- Easy-to-use upload function for supporting documentation
- Status tracking of your requests
- Secure environment to safeguard protected health information (PHI)
If you are not already registered, it's easy to sign up:
- Go to wpshealth.com
- Click on the Resources link and, under Provider Resources heading, select iExchange
- Click on Register
- Fill out the brief form and select Submit
Once registered, the Account Administrator will be notified within 10 business days of the approval and will receive the new iExchange Group ID and a temporary password. Our team can assist you with registration, questions, or technical issues via email at
Coordination of care is crucial among behavioral health and primary care practitioners
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral. The importance of communicating with the customer's other health care practitioners cannot be overstated. This includes primary care practitioners (PCPs) and medical specialists, as well as behavioral health practitioners.
Coordination of care is especially important for customers with complex medical care needs and those referred to a behavioral health specialist by another health care practitioner. All practitioners should obtain the appropriate permission from these 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:
With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.
WPS uses evidence-based medical decision-making tools and processes
The WPS Health Insurance Medical Affairs Department uses internally developed medical policies and science evidence-based resource products, such as MCG Health and Hayes, to form the basis for its clinical reviews. Our medical policies and our use of resource products are approved by our Medical Policy and Quality Improvement Committees.
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 as well as 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 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. The compendium 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
criteria inquiries, contact WPS Medical Affairs at 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, email us at
Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review. The policy updates were emailed to providers in July and we have included them in this issue for your convenience.
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.
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor
or 800-333-5003, ext. 78993.
Additional medical policies for review in December 2018
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
or 800-333-5003, ext. 78993.
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.
Policies currently undergoing review with practicing providers and scheduled for committee discussion include:
- Corneal Treatments and Specialized Contact Lenses
- Glaucoma Surgical Treatments
- Intraoperative Neurophysiologic Monitoring
- Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
- Magnetic Resonance Spectroscopy (MRS), Nuclear Magnetic Resonance Spectroscopy (NMRS)
- Microprocessor-Controlled and Myoelectric Limb Prosthesis
- Noncovered Services and Procedures
- Omnibus Pharmacy Policy for Treatments Reviewed by Medical Affairs
- PET Scan (Positron Emission Tomography)
- Sleep Disorder Testing
- Sleep Disorder Treatment
- Stereotactic Radiotherapy-SRT
- Varicose Vein Treatments
- Vision Therapy (Orthoptic Training, Orthoptics, Pleoptics)
- Wearable Cardiac Defibrillator
Offset claims payments: sample Provider Remittance Advice
In 2018 we implemented the capability to offset claims payments. Click to view
an illustration of how the offset notice will look on your Provider Remittance Advice (PRA) and/or 835. Please share this information with appropriate office staff. If you have any questions, please contact the Provider Services Customer Service line at 888-711-1444.
Do you want to get paid faster?
Enroll for Electronic Funds Transfer (EFT) to receive your payments via direct deposit to your bank account!
Electronic claim filing (EDI) and electronic remittance advice (ERA) are also available at no cost.
If you have any questions regarding EDI, ERA, or EFT, please contact our dedicated EDI team at
800-782-2680, option 2.
WPS Health Insurance | 1717 W. Broadway | Madison, WI |
©2018 Wisconsin Physicians Service Insurance Corporation. All rights reserved. JO9215
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