As we head into fall, it's a good time to remind your patients to get a flu shot. In Wisconsin, influenza vaccination rates are lower than desired. As such, explaining to patients the importance, and the benefits, of receiving a flu shot can pay dividends for all of us.
In this issue, we explain the time frame for corrected claims, how to use our Provider Appeal process, and the tools and processes we use to make evidence-based medical decisions. I hope you find this information useful.
Thank you for the care you give 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.
Jonah Fox, M.D., M.H.A.
Fight the flu: encourage patient vaccinations
Flu season is here. The influenza vaccine rate in Wisconsin for the 2018-19 flu season was 60.0% for children age 6 months to 17 years old, which is below the national average of 62.6%. Adults in Wisconsin hit 48.4%, which was higher than the national average of 45.3%. Providers can produce better results by being proactive and prescriptive about the vaccine. Please encourage your patients to receive a flu shot while they are in the office, if you aren't already doing so.
The time is now, and flu vaccines are covered under customer health plans!
Corrected claims time frame
The time frame for submitting a corrected claim is 180 days, starting with the process date of the original claim, as identified on your provider remittance. A correction to a claim submitted after 180 days will not be eligible for reconsideration.
Example: Process date: July 25, 2019. Claim resubmission must occur before Jan. 1, 2020, for reconsideration.
When and how to use our Provider Appeals process
WPS has a formal Provider Appeal process if you have a claim denied for any of these three reasons:
- Prior authorization is not obtained
- Services are considered not medically necessary
- Treatment is considered experimental, investigational, or unproven
If you do file an appeal, make sure to:
- Submit the dispute in writing via the Provider Appeal Form found on our website
- Submit the form within 45 days of the date of denial listed on your Provider Remittance Advice (PRA)
- Complete the form in its entirety, including the customer number and claim number
- Attach any additional clinical records not previously submitted to be considered in your appeal review
Before providing services, please see wpshealth.com to verify prior authorization guidelines. The best way to prevent the need for an appeal is to obtain authorization prior to services being rendered.
Inquiries related to other issues should be sent to our claim inquiry address:
WPS Health Insurance
P.O. Box 21341
Eagan, MN, 55121
If you're not sure how your inquiry should be handled or where to send it, please contact our Customer Service department at 800-765-4977
Medical policy updates and review
The Medical Policy Committee recently met 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. We ask 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 Coverage Policies
on our website; no password is 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. 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
or 800-333-5003, ext. 78993.
Policies that will be reviewed in the upcoming months include the following:
- Varicose Vein Treatments
- Positron Emission Tomography (PET) Scan
- Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
- Magnetic Resonance Spectroscopy (MRS), Nuclear Magnetic Resonance Spectroscopy (NMRS)
- Omnibus Pharmacy Policy for Treatments Reviewed by Medical Affairs
New policy research and development
- Ankle Arthroplasty, Total (Total Ankle Replacement)
- Meniscal Allograft Transplantation
- Bone Growth Stimulators
- Biofeedback Treatments and Devices
- Neuropsychological Testing
- Deep Brain Stimulation and Responsive Cortical Stimulation
WPS uses evidence-based medical
decision-making tools and processes
The WPS Health Insurance Medical Management 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 at least quarterly to consider scientific evidence and current practice standards for review and approval of new medical policies and 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.
Primary evidence-based clinical resources used include:
- MCG Health: Formerly known as Milliman, MCG Health 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:
- Blue Cross Blue Shield 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 Management at 800-333-5003 with the applicable patient name and customer 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
Utilization Management follows timeliness standards
WPS adheres to the following timeliness standards for review of requested services. The standards include:
- Non-urgent pre-service decisions are determined within 15 calendar days of receipt of the request.
- Urgent pre-service decisions are determined within 72 hours of receipt of the request.
- Urgent concurrent review decisions are determined within 24 hours of receipt of the request.
- Post-service decisions are determined within 30 calendar days of receipt of the request.
These time frames are dependent on the inclusion of necessary clinical information upon receipt of the request. We may request additional medical records if the information submitted to make a determination is not sufficient.
If we cannot make a decision by our standard deadlines, we notify the affected customer and requesting provider that an extension is necessary. The date by which we expect to make a decision is included in that notice.
We consistently strive to exceed these standards and meet the needs of our customers.
Additional electronic functions can save you time and money!
You may be submitting claims electronically, but did you know you can also sign up to receive your payments and remittance electronically?
Save time and money with Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA).
If you are still receiving paper checks, please consider signing up for electronic payment. Benefits include:
- Payments go directly in your bank account
- No more trips to the bank to cash your check
- Eliminate the worry of stolen, damaged, or lost checks
- Cash-flow advantages
- Secure, online system allows providers to enroll in electronic payments with multiple payers at no cost
If you are still receiving paper remittance advice, please consider signing up to receive your remittance electronically. Benefits include:
- Standardized format ANSI X12 835 format (version 5010A1)
- Faster processing of secondary claims
- Automatic payment posting
- Increased productivity and efficiency
- Environmentally responsible with less paper waste
Please contact our dedicated Electronic Data Interchange (EDI) team at 800-782-2680, option 2, to sign up today!
- Bilateral Procedures
- Increased Procedural Services Policy
- Modifier Policy
- Reduced and Discontinued Procedures
- Separate Procedure Policy
- Status B Policy
- Surgical Assist, Co-Surgeon, Surgical Teams
- Venipuncture Policy
- National Correct Coding Initiative (NCCI)
- NCCI Surgical Shoulder
- NCCI Surgical Knee
- Unbundling Edits
- NCCI Surgical Spine Edits
Request for Provider Access
form on our website.
We encourage providers to use the Claim Edit System
(CES) application available within our provider portal to view and edit results and rationale that will be applied to specific code combinations. The CES application is available to all contracted providers through our
. If you do not currently have a provider account, please complete the
For questions regarding medical coding related to policies, contact the Code Governance Committee at
WPS Health Insurance | 1717 W. Broadway | Madison, WI |
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