Our latest issue includes plenty of news you can use. I hope you can take a few minutes to review it.
Of particular interest, you can find out more about our new provider appeal process and how to use it when a claim is denied due to lack of prior authorization or when services are deemed not medically necessary or experimental.
Also, we've included details about our Asthma Population Health Management program and the importance of coordinating care with other providers, including behavioral health specialists.
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.
Jonah Fox, M.D., M.H.A.
Provider Appeal Process
We recently implemented a provider appeal process that may be used if your claim is denied for one of the following reasons:
- Prior authorization is not obtained
- Services are considered not medically necessary or experimental/investigational/unproven
To file a provider appeal, you must submit the dispute in writing via the
Provider Appeal Form
found on our website within 45 days of date of denial listed on your Provider Remittance Advice (PRA). Please complete the form in its entirety.
The easiest way to ensure you don't need to use the Provider Appeal Process is to obtain authorization
prior to the medical and behavioral health services being rendered. By using iExchange to submit a prior authorization request, you'll receive a timely response, sometimes on the same day. iExchange allows you to easily upload supporting documentation so all relevant pieces of the request come in together, and you save on paper costs, too.
We encourage you to use your iExchange account by visiting the
page of our website. If you don't have an account, please visit the page to register.
Our Drug Prior Authorization List can be found on our website. It outlines whether Diplomat, Express Scripts, or WPS performs the review for the drug in question. When seeking a review, please call the appropriate company at the phone number below.
- Diplomat (specialty drugs) 888-515-1357
- Express Scripts (traditional drugs) 800-753-2851
- WPS (other drugs; e.g., hormone-related drugs) 800-333-5003
Please continue to send inquiries related to denial reasons
other than those mentioned above, such as timely filing, code edits, or coordination of benefits to:
WPS Health Solutions
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 888-711-1444.
To ensure your location(s) and practitioner roster are correctly reflected in our online provider directory, Find A Doctor, please notify us of additions, deletions, and changes.
We recommend that you periodically check our
Find A Doctor
tool to ensure we have your practitioner names, specialty, and location information listed accurately. If you find an error, please notify us using one of the following methods:
- Practitioner Data Sheet: The most commonly used form, it allows you to add, terminate, or change data on a practitioner or location.
- Facility Data Sheet: This form allows you to add, terminate, or change information specific to facilities. If you are unsure whether the Facility form is appropriate in your situation, please see the facility types listed on page 2 of the form.
- Full File: If you are currently a health system provider who sends us a full file for updates, you may continue to do so. However, time-sensitive updates may be emailed to GBNetworkDevelopmentDept@AriseHealthPlan.com to expedite the change.
Your help in maintaining our directory is very much appreciated by us, our customers, and referring physicians.
Reimbursement Guideline Highlights
We have completed a yearly review of select reimbursement policies. As a reminder to our providers, we apply the following guidelines:
the American Medical Association's (AMA) guidance on modifiers indicating a separate procedure. The use of modifiers 51, 58, 59, XE, XS, XP, XU, 78, 79, LT, RT, TA-T9, FA-F9, and E1-E4 to override a National Correct Coding Initiative (NCCI) or Correct Coding Initiative (CCI) edit is subject to case-by-case review before reimbursement. Codes appended with these modifiers on a corrected claim may require medical documentation to make the final determination of payment.
We reimburse for bilateral procedures when coded with one unit of a bilateral (50) modifier. It is never appropriate to code more than one unit of a surgery when using a 50 modifier. Services coded with a 50 modifier should adhere to the AMA guidelines for appropriate use. Bilateral procedures utilizing the 50 modifier will be reimbursed at 150% of the rate of a typical unilateral surgical reimbursement.
Surgical Assists, Co-surgeons, and Surgical Teams
We consider the use of modifiers 80, AS, 62, 82, and 81 payable when used in accordance with CPT and AMA guidelines. Assists requiring medical documentation must have a complete explanation of why an assist was medically necessary. Opening/closing, positioning, and holding of surgical equipment are not reasons enough to support an assist's payment. Listing the name of the assistant in the head of the operative report is not enough evidence of participation. It should also be noted that residents cannot bill as assists. If payment is denied based on lack of information for the assistant or co-surgeon, the patient can't be billed for these charges. Physician assistants and nurse practitioners using the AS modifier will be reimbursed at 10% of contracted rate. Physicians using modifiers 80 and 81 will be reimbursed at 20% of contracted rate.
Reduced and Discontinued Procedures
We follow the AMA's guidance on modifiers 52 and 53. The following guidelines apply to the CMS-1500 claim form. The standard for reimbursement of modifier 52 is 50% of the allowable amount for the unmodified procedure. The standard for reimbursement of modifier 53 is 50% of the allowable amount for the unmodified procedure.
can be found on our website under Support and Education. We also encourage providers to use the CES application available within our provider portal to view 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 a
Request for Provider Access
on our website. For questions regarding medical coding related to policies, you may contact the Code Governance Committee at
Asthma Population Health Management Program
Did you know that we have an
Asthma Population Health Management program? The program provides customers with education, resources, and assistance regarding asthma, such as:
- Helping customers understand the importance of following up with their primary providers or asthma specialists after emergency room or urgent care asthma-related visits
- Having our Case Management Registered Nurses work closely with individuals to help them learn to better manage their asthma by:
- Taking their prescribed medications correctly
- Creating a personalized asthma action plan to discuss with their providers
- Eliminating or reducing environmental triggers
- Incorporating active, healthy lifestyles
- Providing customers with smoking cessation support and education regarding available community and online resources
- Educating them about no-cost smoking cessation products available through their health plans
If you have a patient that you feel would benefit from the
Asthma Population Health Management program, please call 800-333-5003. Our Registered Nurse Case Managers are eager to help.
Coordinating Care with Behavioral Health Practitioners
Coordination of care among providers is vital for planning to ensure appropriate diagnosis, treatment, and referral. The importance of communicating with the customer's other health care practitioners cannot be overstated. This coordination 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:
- Discuss with the customer the importance of communicating with other treating practitioners
- Obtain a signed release from the customers and file a copy in the medical record
- Document in the medical record if the customer refuses to sign a release
- Document in the medical record if you request a consultation
- Transmit necessary information if you made a referral
- When you are furnishing a referral, report appropriate information back to the referring practitioner
- Document evidence of clinical feedback (e.g., consultation report) that includes, but is not limited to:
- Treatment plan
- Psychopharmacological medication (as applicable)
With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.
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 under
on our website. There is 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
or 800-333-5003, ext. 78993.
Policies that will be reviewed in the upcoming months include the following:
- Gastrointestinal (GI) pathogen testing using multiplex polymerase chain reaction (mPCR)
- Glaucoma surgical treatments (micro-bypass stents, filtration devices, and shunts)
- Wearable cardiac defibrillator (WCD, wearable cardioverter defibrillator, life vest), implantable cardiac defibrillator (ICD)
- Noncovered services and procedures
- Sleep disorder testing: polysomnogram, split night polysomnogram, sleep study, multiple sleep latency test (MSLT), maintenance of wakefulness testing (MWT), home sleep apnea test (HSAT), home sleep study testing (HST), actigraphy, pulse oximetry, Apnea Link™ devices
- Sleep disorder treatment: positive airway pressure devices and oral appliances (CPAP, BPAP, BiPAP®, BiPAP® ST, BiPAP® with backup, BiPAP®-Auto SV, VPAP, VPAP™ Adapt, VPAP™ Adapt SV, APAP, Adaptive Servo-Ventilation, ASV, oral device, mandibular advancement device)
- Microprocessor controlled and myoelectric limb prosthesis, including, but not limited to: Intelligent prosthesis (Blatchford, U.K.); the Adaptive (Endolite, England); the Rheo (Ossur, Iceland); the C-Leg and Genium Prosthetic Systems (Otto Bock Orthopedic Industry, Minneapolis, Minn.); Seattle Power Knees (models include Single Axis, 4-bar and Fusion, from Seattle Systems); PowerFoot BiOM, iWalk (Bedford, Mass.); Proprio Foot, Ossur (Aliso Viejo, Calif.); Power Knee, Ossur (Foothill Ranch, Calif.); MotoKnee, Electric and Body Powered Fingers
- Hip replacement surgery: total hip arthroplasty, hemiarthroplasty, hip resurfacing arthroplasty, revision or replacement of total hip arthroplasty
- Knee replacement surgery: total knee arthroplasty, patellofemoral arthroplasty, bicompartmental knee arthroplasty, and unicompartmental knee arthroplasty
- PET Scan (positron emission tomography) for groups not using NIA
- Magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) for groups not using NIA
- Magnetic resonance spectroscopy (MRS), nuclear magnetic resonance spectroscopy (NMRS) for groups not using NIA
Affirmative Statement on Incentives
Utilization Management (UM) decision-making is based only on appropriateness of care/service and existence of coverage. The organization does not reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.
Member Rights and Responsibilities
The Member rights and responsibilities listed below set the framework for cooperation among covered persons, practitioners, and WPS.
Our Member Rights and Responsibilities statement specifies that members have:
- A right to receive information about the organization, its services, its practitioners and providers, and member rights and responsibilities.
- A right to be treated with respect and recognition of their dignity and their right to privacy.
- A right to participate with practitioners in making decisions about their health care.
- A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
- A right to voice complaints or appeals about the organization or the care it provides.
- A right to make recommendations regarding the organization's member rights and responsibilities policy.
- A responsibility to provide information, to the extent possible, that the organization and its practitioners and providers need in order to provide care.
- A responsibility to follow plans and instructions for care that they have agreed to with their practitioners.
- A responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
Practitioner Rights Pertaining to Credentialing
Credentialing of practitioners is performed by the Arise Health Plan/WPS Health Insurance Credentialing Department upon initial contracting of practitioners and every three years thereafter. Practitioners undergoing the credentialing process have the following rights:
- You have the right to review a summary of outside information obtained by the Credentialing Department for the purpose of evaluating your application.
- Requests to review a file shall be made to the Credentialing Manager. The review will take place on site during normal office hours.
- Providers shall not have access to references from other practitioners/health care facilities, recommendations, or peer-review protected information received as part of the credentialing process.
- Providers may receive a copy of only those documents provided by or addressed personally to the provider. A written summary of all other information shall be provided to the practitioner by the Medical Director or his/her designee.
- You will be promptly notified of information that varies significantly from the information you have provided and be given the opportunity to submit updated/additional documentation or corrections to the Credentialing Department. The correction of erroneous information must be done, in writing, within 10 days of being notified of the varying information. The Credentialing Department is not obligated to reveal the source of information if disclosure is prohibited by law.
- You have the right, upon request, to be informed of the status of your application at any time. Requests shall be directed to the Credentialing Manager. The Credentialing Manager shall promptly provide the applicant with information regarding the date of application receipt, the general category of items outstanding, and the target approval date.
- You will be notified of the Credentials Committee decision regarding your application via written letter within 60 calendar days of the Committee's credentialing or recredentialing decision.
If you have any questions regarding the contracting process referenced in your Provider Agreement, please contact our Provider Relations Department at 920-490-6903.
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