Spring 2020
Doctor's Note
Dear Colleagues,

Recently, I had the honor of accepting the Leading Change, Creating Value Award from the Business Health Care Group on behalf of WPS Health Solutions, our parent company.
 
The award recognized WPS for our commitment to improving health care transparency, quality, and cost efficiency. These are goals we don't take lightly. For more than 70 years, we have been committed to providing value to the customers and communities we serve, as well as partners such as yourself.
 
I hope you'll find this issue valuable. It includes details on how to access and use the new secure messaging functionality within our provider portal. Additionally, you can learn more about the following:

  • Our updated Provider Manual
  • Member rights and responsibilities
  • Medical policy guidelines

We appreciate 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.
 
Sincerely,
Jonah Fox, M.D., M.H.A.
Medical Director
Secure messaging is available
Did you know that WPS offers a secure way for you to contact Customer Service directly via the provider portal? Secure messages are similar to email, but they can be accessed only through the WPS online health portal. You are allowed up to 4,000 characters for your secure message.

To use secure messaging, go to the Provider section on the website and then click the  Log In  button. Along with your question, please provide:

  • Patient's full name
  • Member identification number or SSN
  • Date of birth
  • One of the following:
  • Last four digits of SSN, if SSN was not given above
  • Full address, including the city, state, and ZIP code
  • Full phone number, including area code
 
When you use our Secure Message Center, you will typically receive a reply within three business days. When a reply has been sent, you will receive a notification on your provider dashboard.
 
If you are not currently using our provider portal, you may register by visiting the link below. Complete the form in its entirety by entering your demographic, practice, and account information. 
Provider Manual revised for 2020
Our Provider Manual has a fresh new look! Check out our website for the updated 2020 Provider Manual . Revisions include additional information about our Credentials Verification Organization (CVO), called Eddy, and updated contact information. Our Provider Manual is designed and produced for our participating providers to promote a clear understanding of our policies and procedures including:

  • Prior authorizations
  • Claims
  • Eligibility

When accessing the Provider Manual, please refer to our website for the most up-to-date information, policies, and procedures.
Contact us with authorization denial notices

If you have questions when you receive a denial notice for services, contact our Integrated Care Management team to review medical policy guidelines and/or discuss determination rationale.

The Integrated Care Manager (ICM) who initially reviewed the service can discuss the medical necessity denial decision and additional information on the reconsideration process. When indicated, the ICM will initiate the process for peer-to-peer discussion with a physician, appropriate behavioral health care specialist, or a pharmacist reviewer for a health plan customer under your care.

Contact us at:
Phone: 608-333-5003
Toll-free phone: 800-333-5003
Fax: 608-226-4777
If you need to appeal

WPS has a provider appeal process when a claim is denied because:

  • Prior authorization is not obtained
  • Service/treatment is considered not medically necessary
  • Service/treatment is considered experimental, investigational, or unproven

When you fill out the  Provider Appeal Form , found at  wpshealth.com , be sure to:

  • Complete the entire form
  • Include the customer number and claim number
  • Attach any additional clinical records

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.
Member Rights and Responsibilities
T he Member Rights and Responsibilities listed below sets the framework for cooperation among covered persons, practitioners, and the insurer. This information is available to all website visitors under Your Rights . 

You have the right to:
  1. Be treated with respect and recognition of your dignity and your right to privacy. You also have the right to the privacy of your medical information unless you allow the release of such information.
  2. Participate in any decision-making regarding your health care.
  3. Have a candid discussion of appropriate or medically necessary treatment options for your medical condition.
  4. Receive the right care at the right level at the right time by the right type of provider for your medical condition.
  5. Receive information about preventive health care that is age and sex specific, and information about remaining as healthy as possible, including self-care and maintenance care for specific chronic diseases.
  6. Receive care according to federal and state mandates.
  7. Voice complaints or appeals about service from WPS Health Insurance or about care received.

You have the responsibility to:
  1. Provide, to the extent possible, information WPS Health Insurance and your physician or health care provider need to care for you.
  2. Be aware of your health care coverage and requirements/limitations under your certificate of coverage, including, but not limited to, pre-certification or prior authorization requirements and exclusions.
  3. Ask questions about your diagnosis, your treatment plan, and how to best manage your health.
  4. Follow the plans and instructions for care on which you have agreed with your physician or other health care provider.
Medical policy guidelines available
Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for a WPS Health Insurance customer under their care.  Medical Polices  can be found on our website by clicking the Providers tab and selecting Medical Policies . If you receive a determination and would like to review the medical policy guidelines used in that decision, you may contact us.
 
We also use tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health, to assist in administering health benefits. Medical Policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.
 
To obtain medical policy guidelines for a specific customer review through Integrated Care Management, submit your request via phone, fax, or in writing to:
                                                                                               
WPS Health Insurance Integrated Care Management  
P.O. Box 8190
Madison, WI 53708-8190

Toll-free phone: 800-333-5003
Fax: 608-226-4777
 
Please include the subject (procedure/service/treatment) for the medical policy in question, along with the customer name and customer number. The policy guidelines are an informational resource, not an authorization, an explanation of benefits, or a contract to provide benefits. Receipt of benefits is subject to satisfaction of all terms and conditions of the customer's contract in effect at the time services are rendered. Medical technology is constantly changing, and we reserve the right to review and update our medical policy guidelines as necessary.
 
We hope that by providing the specific medical policy guidelines upon request, you may better understand the basis for a decision. Our policy guidelines are based on sound medical and clinical evidence and adopted with the involvement of appropriate medical specialists.
 
If you have questions or suggestions about medical policy guidelines or want to request a specific medical policy or MCG guideline, email  medical.policies@wpsic.com  or send the request in writing to WPS Health Insurance Integrated Care Management, Attention: Medical Policy Editor, at the address above.
Medical policy updates and review
The Medical Policy Committee recently met and approved the medical policies due for annual review.
  
 
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 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. 78993.
 
Policies that will be reviewed in the upcoming months include the following:
 
April 2020
  • Hip Replacement Surgery
  • Knee Replacement Surgery
  • Spinal Cord Stimulators
  • Capsule Endoscopy
  • Reduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia

May 2020
  • Back and Nerve Pain Procedures: Radiofrequency Ablation, Facet, and Other Injections
  • Back Pain: Sacroiliac and Coccydynia Treatments
  • Back Pain Procedures: Epidural Injection
  • Wearable Cardiac Defibrillator
  • Infertility and Recurrent Pregnancy Loss Testing and Treatment

June 2020
  • Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
  • Glaucoma Surgical Treatments
  • Tumor Treating Fields (Alternating Electric Field Therapy)
  • Noncovered Services and Procedures
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