WPS Winter 2016 Provider Connection

Winter 2016

Doctor's Note

Greetings, Colleagues.

As this year comes to a close, we hope you have found our provider newsletter to be a useful tool and have been sharing it with your team. Please read on for information about upcoming drug formulary changes for 2017, information related to telemedicine, Disease Management services available to your patients with asthma, hypertension, and low back pain, new features available to you and your team to help with radiology prior authorization, and credentialing.

Feel free to contact me with any questions at 1-608-977-8981 or [email protected].

Best of health,

Michael Ostrov, M.D., M.S.
Vice President and Chief Medical Officer

Updates made to Prescription Drug Program

Information regarding WPS Health Insurance's Prescription Drug Program can be found on our website, wpsic.com. Specifically, you can access:

The Drug Prior Authorization List which identifies the applicable medications as well as who to contact to initiate the process
Specialty drug approval policies (this is part of our website's Medical Policy section)
Formulary/Preferred Drug List

Please note the following Formulary/Preferred Drug List changes for 2017

Preferred Drug List Additions*

IMPADIVO	NARCAN NASAL	OCALIVA
TECENTRIQ	UPTRAVI	VITOGARD
VENCLEXTA	VONVENDI	XURIDEN

* May be subject to prior authorization requirements.

Preferred Drug List Exclusions with Alternatives**

Preferred Drug List Exclusion	Preferred Alternatives	Preferred Drug List Exclusion	Preferred Alternatives
ABSTRAL	Fentanyl lozenges, LAZANDA	NUTROPIN AQ	GENOTROPIN, HUMATROPE, NORDITROPIN
ACCU-CHEK Meters and Strips	ONETOUCH Meters and Strips	OLYSIO	VIEKIRA, TECHNIVIE
ACUVAIL	Bromfenac drops, diclofenac drops, ketorolac drops, ILEVRO, NEVANAC, PROLENSA	OMNARIS	Budesonide, flunisolide, fluticasone, mometasone, QNASL
ADVOCATE Meters and Strips	ONETOUCH Meters and Strips	OMNITROPE	GENOTROPIN, HUMATROPE, NORDITROPIN
ALVESCO	ARNUITY, ASMANEX, FLOVENT, PULIMCORT, QVAR	ONGLYZA	JANUVIA, TRADJENTA
APIDRA	HUMALOG	ORENCIA	ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
ARANESP	PROCRIT	PANCREAZE	CREON, ZENPEP
ASACOL HD	Balsalazide, sulfasalazine, APRISO, LIALDA, PENTASA	PERTZYE	CREON, ZENPEP
BECONASE AQ	Budesonide, flunisolide, fluticasone, mometasone, QNASL	PRECISION Meters and Strips	ONETOUCH Meters and Strips
BREEZE Meters and Strips	ONETOUCH Meters and Strips	PROVENTIL HFA	PROAIR HFA, VENTOLIN HFA
CETRAXAL	Ciprofloxaxin otic, ofloxacin otic, CIPRODEX	SAIZEN	GENOTROPIN, HUMATROPE, NORDITROPIN
CIMZIA	ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR	SIMPONI	ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
CONTOUR Meters and Strips	ONETOUCH Meters and Strips	SOVALDI	VIEKIRA, TECHNIVIE
DAKLINZA	VIEKIRA, TECHNIVIE	SUBSYS	Fentanyl lozenges, LAZANDA
DELZICOL	Balsalazide, sulfasalazine, APRISO, LIALDA, PENTASA	TALTZ	ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
DIPENTUM	Balsalazide, sulfasalazine, APRISO, LIALDA, PENTASA	TANZEUM	BYDUREON, BYETTA, TRULICITY
DUEXIS	Ibuprofen plus famotidine	TESTIM	ANDROGEL, AXIRON
EMBRACE Meters and Strips	ONETOUCH Meters and Strips	TRUETEST Meters and Strips	ONETOUCH Meters and Strips
ENDOMETRIN	CRINONE	TRUETRACK Meters and Strips	ONETOUCH Meters and Strips
EPOGEN	PROCRIT	ULTRESA	CREON, ZENPEP
ESTROGEL	DIVIGEL	UNISTRIP Meters and Strips	ONETOUCH Meters and Strips
EVZIO	Naloxone syringe, NARCAN nasal spray	VELTIN	Clindamycin/benzoyl peroxide, clindamycin/tretinoin, ACANYA, ONEXTON
FENTORA	Fentanyl lozenges, LAZANDA	VERAMYST	Budesonide, flunisolide, fluticasone, mometasone, QNASL
FORTESTA	ANDROGEL, AXIRON	VICTORY Meters and Strips	ONETOUCH Meters and Strips
FREESTYLE Meters and Strips	ONETOUCH Meters and Strips	VICTOZA	BYDUREON, BYETTA, TRULICITY
GLUMETZA and Generics	Metformin extended-release	VIMOVO	Omeprazole plus naproxen
ISTALOL	Betaxolol drops, levobunolol drops, timilol drops, ALPHAGAN P, COMBIGAN	VOGELZO	ANDROGEL, AXIRON
KAZANO	JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR	XOPENEX HFA	PROAIR HFA, VENTOLIN HFA
KINERET	ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR	ZEPATIER	VIEKIRA, TECHNIVIE
KOMBIGLYZE XR	JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR	ZETONNA	Budesonide, flunisolide, fluticasone, mometasone, QNASL
MIRCERA	PROCRIT	ZIOPTAN	Latanoprost drops, travoprost drops, LUMIGAN, TRAVATAN Z
NATESTO	ANDROGEL, AXIRON	ZOMACTON	GENOTROPIN, HUMATROPE, NORDITROPIN
NESINA	JANUVIA, TRADJENTA	ZYCLARA	Diclofenac gel, fluorouracil cream, imiquimod cream, CARAC, PICATO
NOVOLIN	HUMULIN
NOVOLOG	HUMALOG

** WPS has a pharmacy exception process. Exceptions must be approved in advance for coverage.

If you would like a copy of this information, please contact Provider Contact Center at 1-800-765-4977.

Quarterly Medical Policy Updates

The Medical Policy Committee met on Sept. 9, 2016, this quarter and approved medical policies due for annual review.

View the Medical Policy Updates online in our Provider Portal. View the November 2016 updates .

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.

The complete library of our medical policies can be found at: wpsic.com/providers/medical-policies/index.shtml. No password required!

If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email [email protected] or call 1-800-333-5003, ext. 77196.

For questions regarding medical coding related to policies, please contact the Code Governance Committee at [email protected]. This email and other contact information can be found on our website as well as in the Provider Portal.

The Prior Authorization List on our website has a new look and logo but the same content, which means you can continue to use it now and after the effective date of Jan. 1, 2017.

Reminder regarding genetic testing: Prior authorization is required for genetic testing. To expedite authorization, please provide documentation directly from the ordering provider.

Telemedicine coverage defined for 2017

As of Jan. 1, most 2017 Member Certificates include coverage for telemedicine services. Covered telemedicine services are defined as:

Telemedicine services provided by a health care provider at a distant site to a covered person at an originating site via interactive audio-visual telecommunication. The originating site and the distant site must be:

A physician's office or the office of another health care provider, such as a nurse practitioner, physician assistant, certified nurse-midwife, or psychologist
A convenient care clinic
A hospital
A skilled nursing facility

Excluded from coverage are:

Telemedicine services that do not include direct, in-person audio/visual contact between the health care provider and the covered person
Telephone evaluation and management services
Transmission fees
Website charges for online patient education material
Online medical evaluations

Phone and internet consultations provided by our approved telehealth service provider, Teladoc^®.

We provide various plans, so coverage of telemedicine benefits may vary from member to member. To verify telemedicine benefits for your patient, please contact the phone number listed on the member's ID card or our Provider Contact Center at 1-800-765-4977.

Clean claims are important for timely processing

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. It is also a claim that contains no substantial issue regarding the insurer's responsibility for payment, including, but not limited to, subrogation or coordination of benefits issues. Clean claims must be submitted using current UB-04 and CMS 1500 forms (or any successor forms) for paper claims; current HIPAA standard professional or institutional claim formats for electronic claims, as applicable; and accepted coding standards.

The number of days to file a claim is counted from the date of service to the date of our receipt of a clean claim. If you receive a letter from us indicating a claim was not accepted, resubmission is necessary; it refers to an unclean claim and is not considered a received claim. In this scenario, we suggest you address the issue of missing or invalid information. Correct the error and resend as soon as possible to meet the timely filing parameters outlined in our Agreement.

Disease management programs assist your patients

BENEFITS
Supported Self-Care	A case manager designated to help the member feel better soon and coordinate services
	Access to pharmacists who can help address member medication needs and concerns
	Simple ways to help members record symptoms and vital signs by phone or computer
Support Tools	Additional information obtained from monitoring comorbid conditions
	Timely alerts regarding changes in a member's condition and vital signs
	Information for members to self-manage effectively to prevent an emergency
	Information and resources on managing conditions, medication management, healthy eating, exercise, and more

As a physician, it can be difficult to manage care for patients with low back pain, hypertension, or asthma. That's why we're excited to let you know we are here to help with these common conditions.

WPS Health Insurance offers FREE disease management programs to members diagnosed with these conditions. These programs encompass a number of initiatives designed to help patients reach and maintain good health, such as supporting the doctor-patient relationship and a plan of care that emphasizes the control of the disease and its complications.

Our commitment to our members means providing the very best service. That's why members with these conditions are automatically enrolled in the program and receive an information kit in the mail to help answer any questions. For more information or answers to your questions, please call 1-800-333-5003, Monday through Friday, 8 a.m. to 4:30 p.m., or visit the Disease Management page at wpsic.com .

Affirmative Statement on Incentives

Utilization Management (UM) decision-making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.

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. WPS may request additional medical records if the information submitted to make a determination is not sufficient. Prior authorization requests and clinical information should be submitted via iExchange, fax at 1-608-226-4777, or mail to:

WPS Preauthorization

P.O. Box 8190

Madison, WI 53708

If WPS cannot make a decision by our standard deadlines, we notify the affected member 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 members.

Member Rights and Responsibilities

The Member Rights and Responsibilities listed below set the framework for cooperation among covered persons, practitioners, and insurer.

Member Rights as a Health Plan Member

The right to be treated with respect and recognition of your dignity and right to privacy.
The right to a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
The right to participate with practitioners in making decisions about your health care.
The right to receive information about us, our services, our network of health care practitioners and providers, and your rights and responsibilities.
The right to voice complaints or appeals about us or the care we provide.
The right to make recommendations regarding the members' rights and responsibilities policies.

Member Responsibilities as a Health Plan Member

The responsibility to supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
The responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.
The responsibility to follow the treatment plan and instructions for care that have been agreed on with your practitioners.

Do you know your practitioner credentialing rights?

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. Credentialing Manager shall promptly provide applicant with information regarding date of application receipt, general category of items outstanding, and 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 credentialing process, please contact the Credentialing Manager at 1-920-490-6952. If you have any questions regarding the contracting process, please contact Provider Relations at 1-608-977-6618.

WPS Health Insurance | 1717 W. Broadway | Madison, WI | wpsic.com

27885-021-1612

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