Spring 2017
Doctor's Note

Dear Colleagues,
The articles and guidelines in this newsletter are intended to enhance our collaboration with you. You'll find tips on using our online Provider Portal, information about our Site of Care Program for medication administration, about the prior authorization submission process your staff uses, and about obtaining details of our medical coverage policies.
 
Please see our friendly reminder regarding information our customer services staff requires for HIPAA compliance when answering your calls.
 
Thank you for your continued work with WPS Health Insurance. If you have any questions, you can contact me at 608-977-8981 or [email protected].
 
Best of health,


Michael Ostrov, M.D., M.S.
Vice President and Chief Medical Officer
Site of Care Program for specific drugs may add convenience for patients

Here are answers to the most commonly asked questions regarding our Site of Care Program:

Q: What is a Site of Care Program?

A: A program that ensures services that can be provided in multiple settings (outpatient hospital, clinic, home) are provided in the most cost-effective setting that is appropriate for a patient. Providers/health care systems often charge different prices based upon the setting in which the service is provided.

Q: How does this relate to drugs?

A: Certain drugs, which are often provided in a doctor's office or outpatient clinic of a hospital, can be safely administered in the home by a nurse (Remicade, immune globulin) or self-administered by a patient (Neulasta, Neupogen).

Q: Is this safe for patients?

A: We have partnered with Diplomat, which has years of experience in home treatments. Diplomat provides patients in-depth training on self-administered drugs. For infusion treatments, they use highly trained health care professionals for their home visits. Diplomat professionals are trained to identify and treat allergic reactions and other adverse events. However, if you have concerns, we permit providers to give initial doses in the office to observe how patients respond.

Q: How do patients get established with Diplomat?

A: As part of the prior authorization approval process, Diplomat contacts your office if a drug is subject to the Site of Care Program. Diplomat asks you for a prescription at that time and then works out the logistics directly with the patient. It's during this process that you can discuss giving initial doses under your observation.

If you have further questions, please contact us at 800-332-0899.
Provider Portal tips: Patient Inquiry  

Did you know the Provider Portal offers benefit information under the Patient Inquiry feature? This enables you to verify the following information in real time without having to place a call to Customer Service:
  • Benefits
  • Eligibility
  • Deductible/Coinsurance/Copay/Accumulation Limits
  • Member Address
  • Other Insurance Information
  • Primary Care Practitioner (if applicable)
You simply need the member's name or member number from their ID card, along with their date of birth, to get started. Click on the patient's name for more detailed subscriber and policy details, as well as recent claim information.
 

 
If you're not already using our Provider Portal, please send an email to [email protected]
with the following information: Administrator name, email address, tax ID, practice name, and a list of all clinic locations (including addresses). 
Bill type is important on corrected claims      
 
When filing corrected claims, be sure to use the appropriate bill type for the services provided in
box 4 of the UB form and box 22 of the HCFA form. If you are unsure of the correct bill type to use, please refer to your HIPAA implementation guide for institutional and professional claims.
 
Include the original claim number supplied on the 835 remit or Provider Remittance Advice (PRA) when submitting a corrected claim. Both the bill type and claim number are important to include whether you submit electronically or on paper, and will prevent delays in processing. Please see our Corrected Claim Cover Sheet when refiling via paper.
Verification necessary over the phone for protection of members' personal health information
 
Our processes incorporate HIPAA Privacy Guidelines, when applicable. To protect the personal health information (PHI) of our members, our Customer Service Representatives will ask you to provide four unique identifiers before releasing PHI.
 
These identifiers are:
  1. Full name
  2. Member identification number or SSN
  3. Date of birth
  4. One of the following:
  • Last four digits of SSN (if SSN was not given above)
  • Full address (including city, state, and ZIP code)
  • Full phone number (including area code)

To save time, please have this information handy when you call. We appreciate your cooperation with securing our members' information. 
Quarterly Medical Policy Updates

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: wpsic.com/providers/medical-policies/index.shtml. No password required!
 
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor at [email protected] or 800-333-5003 ext. 77196.  
When is prior authorization needed?
 
Prior authorization, also known as pre-service authorization, pre-authorization, or pre-certification, is required for a variety of health services. Please refer to the WPS Prior Authorization List , which is updated regularly on our website. Helpful tips for filing prior authorization requests may be found in our Prior Authorization section.
 
We will also review a prior authorization request if it is submitted when a member or provider is unclear if a service will be covered. This may include new and emerging technology and procedures that may be a certificate exclusion or benefit since medical language is complicated and many procedures sound alike. When in doubt, prior authorize. We make determinations based on the specific service that is requested and not solely on a service billing code. The member maintains the right for a review determination and an appeal to that determination prior to services rendered.   
 
Customer Service may be reached by calling 800-765-4977 or through the Message Center in our Provider Portal.
Contact us with authorization denial notice questions

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 Medical Management team in our Medical Affairs Department by phone, fax, or in writing.
 
Physicians and other practitioners may speak with the Integrated Care Manager (ICM) who initially reviewed the service to discuss the medical necessity denial decision and additional information reconsideration process. When indicated, the ICM will also initiate the process for peer-to-peer discussion with a physician, appropriate behavioral health specialist, or a pharmacist reviewer for a health plan member under your care.
 
Contact us at:
WPS Medical Affairs Dept.
P.O. Box 8190
Madison, WI 53708-8190
 
Phone: 608-226-8003
Toll-Free Phone: 800-333-5003
Fax: 608-226-4711 
Medical policy guidelines available upon request

Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for a health plan 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 and ask for a copy.
 
We also use tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. Medical Policies and MCG 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, submit your request by phone, fax, or in writing.
WPS Medical Affairs Dept.
P.O. Box 8190
Madison, WI 53708-8190
 
Phone: 608-226-8003
Toll-Free Phone: 800-333-5003
Fax: 608-226-4711
 
Please include the subject (procedure/service/treatment) for the particular medical policy guideline 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 general questions or suggestions about medical policy guidelines or want to request a specific medical policy or MCG guideline, email [email protected] , send the request in writing to the Medical Affairs, Attention: Medical Policy Editor, at the address above, or call 608-977-7196. 
WPS Health Insurance | 1717 W. Broadway | Madison, WI | wpsic.com
27885-021-1702
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