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Doctor's Note
In our provider newsletter, I want to highlight activities that WPS is doing on your behalf to continue to build a collaborative and supportive relationship to address your practice needs.
Developing and updating medical policies that reflect an evidence-based and prudent approach to evaluation and treatment remains a high priority for us. We welcome your feedback, questions, or concerns related to any of our medical policies.
An example of one such activity is the successful launch of the Low Back Pain Collaboration project. Educational webinars geared toward chiropractors and primary care physicians were rolled out in April 2016. The goal is to encourage collaboration through excellent communication and a structured approach to care using national guidelines. In the next several months, network primary care physicians will receive a list of chiropractors in their area who have completed the training and agree to work within this structured approach.
On April 2, our Chief Medical Officer, Dr. Colmenares, presented the keynote address at the Wisconsin Medical Society's Annual Meeting. His topic was entitled, "
Engaging Physicians in Meaningful Measurement." The focus of his presentation was using measures of appropriateness (the value of the intervention) in addition to the traditional quality metrics. Our Medical Affairs Health Care Informatics (HCI) team has been instrumental in this project. Key value metrics are being developed for several specialties.
As always, I am available to respond to questions or concerns that you may have.
Sincerely,
Michael Ostrov, M.D., M.S.
Medical Director, Network and Quality
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New address for paper claim submissions
If you previously submitted claims to PO Box 981641, El Paso, TX, please use the address below, effective Aug. 1, 2016, for all paper claims and claim-related correspondence.
WPS Health Insurance
PO Box 21341
Eagan, MN 55121
Members will receive ID cards with the new address upon renewal. Therefore, you may continue to see the Texas address until a new card is issued. Please share the Eagan, MN address with your staff.
Electronic claim submission is available to all providers. If you are interested in submitting claims electronically, please contact our Electronic Data Interchange Department (EDI) at 1-800-782-2680, Option 1, from
7:55 a.m. to 4:30 p.m. CT.
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EDI phone system options updated
The EDI Department implemented a new phone system and there are some new phone options. The EDI phone number is still 1-800-782-2680, but once you're in the system, you'll notice some changes.
Press Option 1 for questions about online registration, password resets, how to log in, missing files, or any other technical concerns. Then choose one of the following:
- 4= Arise Health Plan
- 6= WPS Health Insurance
Press Option 2 for questions about EDI enrollment for claims submission, electronic remittance, and electronic funds transfer.
The EDI Help Desk and EDI Marketing staff are available from 7:55 a.m. to 4:30 p.m. CT.
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IVR system temporarily unavailable beginning mid-June
Effective Monday, June 13, our Speech-Enabled Interactive Voice Response (IVR) system will not be available. This is necessary in order to launch a new and more robust IVR system this fall. This means when you call, you will be greeted by a Provider Services representative after you identify yourself as a provider in the first menu option. You can still receive information related to eligibility, benefits and claim status on our website at www.wpsic.com 24/7.
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Benefits of using the Provider Portal Claim Center
The Claim Center accessed through our Provider Portal provides information on claim editing, submission, and status.
In this issue, we'd like to share the benefits of using CES (Claims Editing System), our online code combination simulation tool, which is available to you in the Claim Center. The online tool allows you to
enter billing specifics related to a particular service.
Query parameters include procedure codes, modifiers, diagnostic codes, date(s) of service, patient gender, date of birth, and place of service. The results and rationale related to your query will be displayed and can be downloaded to a PDF.* This allows greater transparency of the code combination edits being utilized by WPS.
The example below is an age-specific CPT Code for the shingles vaccine. The patient's birth date, date of service, CPT code 90736, and diagnosis code Z000 for a general exam are entered. For services provided on or after Oct. 1, 2016, be sure to change the Code Type to ICD-10.
The results will let you know if any errors will be flagged in our claims processing system. As you can see below, the CPT Code submitted is not appropriate for the age of the patient. The Flag Status shows you a claim submitted in this manner will deny. The Disclosure section provides you with detailed rationale related to Flag Description.
If you are not familiar with this feature in the Provider Portal, we encourage you to try it today. Not only is it helpful prior to submitting a claim, but useful if you have the need to resubmit a claim that was denied.
Please contact our Customer Service Provider Line at 1-800-765-4977, if you have questions.
*Coding combinations and results do not guarantee payment of claims. For benefit and coverage questions, please see the Patient Inquiry area in the Provider Portal.
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Provider Relations Department has new personnel
The Provider Relations Department has two new faces.
Providers in the north-central area of Wisconsin may be aware that Debbie Wadzinski, Health Plan Manager, retired in April 2016, after 14 years of service.
Stacy Willems has replaced Debbie as the Provider Relations contact for the north-central region of the state. Stacy joined our department March 21, 2016, as a Contracting Coordinator. Her name may be familiar to you, as she has been with WPS for 17 years in various capacities, most recently as the Unit Coordinator of our Provider Development Department. Stacy can be reached at 608-226-4991 or
Stacy.Willems@wpsic.com.
Mark Xistris joined our department on Leap Day, Feb. 29, 2016, as the new Vice President of Provider Relations at WPS Health Solutions. With well over 20 years in the health care industry, Mark was previously the Vice President of Business Development and Provider Relations at The Alliance. Mark succeeds Brett Davis, who became President of Aspirus Arise Health Plan of Wisconsin. Mark may be contacted at 608-223-5831 or Mark.Xistris@wpsic.com.
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Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review.
Click here 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.
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email
medical.policies@wpsic.com
or call 1-800-333-5003 ext. 64133.
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Medical policy guidelines available upon request
Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for a WPS Health Insurance member under their care. If you have received a determination and would like to review the medical policy guidelines used in that decision, you may contact us.
WPS also uses 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 member review through WPS Medical Affairs, submit your request by phone, fax, or in writing.
WPS Medical Affairs.
P.O. Box 8190
Madison, WI 53708-8190
608-226-4711 │ 800-333-5003
Fax: 608-226-8003
Please include the subject (procedure/service/treatment) for the particular medical policy in question, along with the patient name and member 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 member'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 Medical Affairs, Attention: Medical Policy Editor, at the address above.
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Have questions about an authorization denial notice?
Contact us.
WPS Health Insurance physicians and other practitioners may contact a physician, appropriate behavioral health specialist, or a pharmacist reviewer to discuss medical necessity denial decisions for a WPS Health Insurance member under their care.
If you have received a denial notice for which you would like to review medical policy guidelines and discuss determination rationale, you may contact the WPS Medical Management Department by phone, fax, or in writing.
WPS Medical Management Dept.
P.O. Box 8190
Madison, WI 53708-8190
608-226-4711 │ 800-333-5003 | Fax: 608-226-8003
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WPS Health Insurance| 1717 W. Broadway | Madison, WI |
www.wpsic.com
27885-021-1606
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