Fall 2017
Doctor's Note

Dear Colleagues,
Thank you for your continued participation in our network. Highlights of this newsletter include updates to the Provider Manual, flu vaccine reminder, Members Rights and Responsibilities, the definition of a new patient for E&M billing purposes, significant improvements to the iExchange web portal, our Health Management program, Clinical Practice Guidelines updates, and a number of Medical Policy updates, including back pain and gender dysphoria treatments.
Feel free to contact me with questions or concerns at 608-977-8981 or  [email protected] .
 
Best of health,


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

Our Provider Manual is designed and produced for our preferred providers to promote a clear understanding of our policies and procedures, including provider services, prior authorization, claims, and eligibility. Please see our WPS Provider Manual for our most recent edition.
While reviewing, you may notice the Prior Authorization section has been updated to include an easy-to-read list of services that require prior authorization, a Quality Improvement section has been added, and a current member ID card sample is provided.
Focus on flu vaccine

The season is upon us: fall, football, and flu vaccine. Our influenza vaccine rate in Wisconsin for the 2016-17 flu season was 42.6%, which is below the national average of 47.5%. When providers are proactive and prescriptive about the vaccine, better results can be reached. If you're not already doing so, adopting a "While you're here, let's give you your flu vaccine" approach may help.
 
The time is now and flu vaccines are covered under member health plans!
 
For more tips to increase influenza vaccination rates in your practice, please see the Centers for Disease Control and Prevention Influenza (Flu) 2017-18 Summary of Recommendations.
Member Rights and Responsibilities

The Member Rights and Responsibilities listed below set the framework for cooperation among members, practitioners, and WPS Health Insurance.
Member Rights
  • To be treated with respect and recognition of their dignity and right to privacy.
  • To a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  • To participate with practitioners in making decisions about their health care.
  • To receive information about us, our services, our network of health care practitioners and providers, and their rights and responsibilities.
  • To voice complaints or appeals about us or the care we provide.
  • To make recommendations regarding the members' rights and responsibilities policies. 

Member Responsibilities as a health plan member

  • To supply information (to the extent possible) that we and our practitioners and providers need in order to provide care.
  • To understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
  • To follow the treatment plan and instructions for care that have been agreed on with their practitioners.
Tip to avoid claim denials with new patients
 
American Medical Association (AMA) guidelines define a new patient as "one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care profession of the exact same specialty and subspecialty who belongs to the same group practice within the past three years." When advanced practice nurses and physician assistants are working with a physician, they are considered as working in the same subspecialties as the physician.
We've recently enhanced our claims editing software related to new and established patients. Our policies apply the AMA (American Medical Association) and E/M (Evaluation and Management) guidelines. Please keep this in mind should you receive a denial on a new patient visit claim.
If you have questions related to this policy, please refer to the guidelines and decision tree referenced in the 2017 CPT Professional Edition. Further questions can be directed to our Code Governance department at [email protected] .
iExchange® makes prior authorizations faster

What is iExchange?
iExchange is a web-based portal for providers to submit prior authorization requests to our Integrated Care Management team for review. The days of faxing in information, hoping it was received, and waiting with no update on the status of the review are over. iExchange allows you, as the provider, to submit an electronic request for prior authorization (other than drug prior authorizations), upload supporting documentation, and even track on the status of the review. Not only that, iExchange allows automatic approval of certain requests, which means you can receive authorization in seconds rather than days.
 
Benefits of iExchange
iExchange is centered around saving you time and making the prior authorization process easier on your team. Some of the benefits include:
  • Automatic approval of specific requests
  • Easy-to-use upload of supporting documentation
  • Elimination of hand writing errors
  • Elimination of fax problems
  • Status tracking of requests
  • Secure environment for protected health information (PHI) protection
We'd love to show you iExchange
Over the past several months, our team has been working on improving the functionality of iExchange to better meet your needs as a provider. The most important improvement is the dramatic increase in services that can be automatically approved. Our outreach is designed to educate and encourage the use of the iExchange portal for all prior authorizations submitted to us. The outreach team created a webinar and will be setting up sessions for clinics to attend online. We are offering in-person, hands-on education and support to providers and their teams.
 
How to register:
The use of iExchange is FREE and it's easy to register as a new user:
  1. Go to wpsic.com
  2. Click on the  Providers tab
  3. Under Providers, choose the iExchange link
  4. Go to the Register for iExchange link in the left navigation bar
  5. Fill out the brief form and select Submit
The Account Administrator will be notified in 10 business days of the approval and will receive the new iExchange Group ID and a temporary password.
 
Our team can assist you with registration, questions, or technical issues by email at: [email protected] . 

We strive to continuously improve our services to make iExchange easier to use and as efficient as possible for you, our providers. Our goal is to have 100% of all prior authorization requests submitted through iExchange by mid-2018. We ask for your assistance in helping us achieve this goal, all while making your life easier.
Health Management Program assists your patients
 
BENEFITS
Supported Self-Care
A case manager designated to assist members 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 via 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
The Health Management Program (previously known as Disease Management) is an integrated approach to health care that identifies members with chronic medical conditions. 

Our Health Management Program encompasses many initiatives designed to help members reach and maintain good health and support the doctor-patient relationship and plan of care. The intent of the program is to emphasize control of the member's condition and its complications, and to use cost-effective, recommended guidelines and self-management tools.

WPS offers this program at no additional cost to members diagnosed with hypertension or asthma.

Our commitment to our members means we provide the very best service to improve health. That's why members identified and enrolled in the program will receive an information kit in the mail to help answer any questions. 
For more information or answers to your questions, please call 800-333-5003, Monday through Friday, 8 a.m. to 4:30 p.m., or visit the Disease Management page at wpsic.com 
Clinical Practice Guidelines a valuable resource for providers

Clinical Practice Guidelines (CPGs) are resources designed to assist clinicians in prevention, diagnosis, and treatment of specific conditions or diseases . They are not intended to replace professional judgment or to establish a rigid protocol for patient management. These guidelines are developed through analysis of nationally published evidence based clinical literature combined with expert consensus. They present an opportunity to significantly reduce variation in the clinical setting and provide part of a framework necessary for measuring and improving the quality of care.
 
CPGs are not intended to determine plan benefits or utilization management authorization determinations. They may however be used as references in our Medical Policies and Care Management Programs. WPS has chosen nationally recognized guidelines that reflect the current literature and research about treatment protocols, and best practices, which we hope you will find useful in your practice.
 
Recent updates include the 2017 Standards of Medical Care in Diabetes from the American Diabetes Association and the July 2017 American Academy of Family Practice (AAFP) Summary of Recommendations for Clinical Preventive Services.  Links are provided to regularly updated Center for Disease Control and Prevention (CDC) resources for immunization and the United States Preventative Services Task Force (USPSTF) recommendations.
 
A new addition to our list is the CDC Get Smart website. This site provides interactive information for patients ( Get Smart About Antibiotics), and recommendations for providers from the CDC and National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion to support your efforts in wise antibiotic prescribing.
 
The CPGs are available on our website at Clinical Practice Guidelines .
How to bill telemedicine services   

WPS Health Insurance follows industry standards relating to standard billing modifiers and coding. These guidelines are like those established in UB-04 and CMS's Medicare Database.
 
Some member certificates now include coverage for telemedicine services. We'd like to remind you to use modifier-95 when submitting claims for synchronous telemedicine.
 
Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
 
We appreciate your use of this informational modifier. Please see our website for a complete listing of our  Modifier Reimbursement Policies .
Quarterly Medical Policy Updates

The Medical Policy Committee met this quarter 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 Medical Policies. Our Prior Authorization list can be found at WPS Prior Authorization List . 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.
Please notify WPS of roster and location changes

Current members, potential members, and providers use our online provider directory, Find A Doctor, to verify whether a provider participates in our provider networks.
 
To keep the directory up to date, we count on you, our preferred providers, to notify us of roster and location changes in an accurate and timely manner. This allows us to market you to our members appropriately. It assists users looking for a primary care practitioner, as well as those who are referred to a specialist.
 
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: Most commonly used form, as 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 two of the form.
  • Full File: If you are currently a health system provider that sends us a full file for updates, you may continue to so. However, time-sensitive updates may be emailed to [email protected] to expedite the change.
Your help in maintaining our directory is very much appreciated.
Some EDI claim functions moving to a third party

WPS Health Insurance will soon begin migrating some EDI claims process functions to a third party, Smart Data Solutions (SDS). Please watch for more information in the near future. 
 
This change will not affect your connectivity with us or how you send files. You will also continue to receive acknowledgement files (TA1, 999, 277CA) in the same location as today. Due to enhancements to our validation edit process, you may receive multiple 277CAs for claims within a single file/transaction.
 
For questions on electronic claim file rejections and acknowledgements, please contact SDS at [email protected] or 855-297-4436. For all other EDI questions, continue to contact WPS at [email protected] or 800-782-2680.
Updates to Medical Affairs fax numbers and forms

We've made some updates you should know about. Our Medical Management team is now called our "Integrated Care Management" team. The Medical Affairs Integrated Care Management team's fax number has also been updated. Please use the following fax numbers in the future:
  • WPS Employee Group members: 608-226-8016
  • All other members: 608-226-4777
Additionally, we've updated the following forms:
Find these updated forms and more on our Provider Forms page .
WPS Health Insurance | 1717 W. Broadway | Madison, WI | wpsic.com
27885-021-1708
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