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Doctor's Note
Dear Colleagues,
Allow me to introduce myself. My name is Jonah Fox, and I joined WPS Health Solutions as Medical Director in February. As a native of Madison, Wis., I am eager to return to my Wisconsin roots as I work with Aspirus Arise.
I received both an M.D. and an M.H.A. degree from Virginia Commonwealth University, and a B.S. in economics from the University of Wisconsin-Madison. I completed my graduate medical training at the University of Virginia and am board-certified in physical medicine and rehabilitation.
In addition to the practice of medicine, my experience includes strategic, financial, and operational roles within both the public and private sectors. I have designed and implemented solutions surrounding medical management, care delivery, and clinical quality and value strategy for health care payers and providers.
I hope you'll find my expertise helpful to your practice. These newsletters are a great opportunity to share important policy changes and initiatives at Aspirus Arise. We want you to know where we're headed!
In this issue, we have stories about our:
- Complex case management program
- Simplified EFT and ERA enrollment
- Prior authorizations through iExchange®
- Partnering with pharmacies for vaccinations
- New credentialing partner
- And more
We appreciate the care you give your patients and our customers. If you have any questions, please contact me by email at
[email protected]
or by phone at 608-977-8038.
Sincerely,
Jonah Fox, M.D., M.H.A.
Medical Director
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Partnering with Pharmacies for Vaccinations
Wisconsin's vaccination rates for children, adolescents, and adults have been steadily increasing, but there is plenty of room for improvement. Improving vaccination rates for members is one of the most important public health activities we can support.
Two of the primary barriers that prevent our members from receiving preventive vaccinations are access to care and availability of services that are convenient. To address this, we partnered with the Wisconsin Pharmacy Society to promote best practices in vaccination administration.
For almost all our products, we cover 100% of all costs associated with all preventive vaccinations. That includes vaccines administered at pharmacy locations. In just the past two years, we have seen a 40% increase in vaccinations provided at pharmacies. In fact, more than 25% of all influenza vaccinations administered to our members were provided at pharmacies.
These increases in vaccination administration at pharmacies occurred at the same time vaccination rates increased in traditional medical settings. Using pharmacies as an added health care location helps efforts to keep our members healthy.
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New Enrollment Partner for Electronic Processes
WPS Health Solutions is partnering with the nationally recognized Committee for Affordable Quality Healthcare (CAQH) for electronic remittance advice (ERA) and electronic funds transfer (EFT) enrollment. CAQH not only simplifies the credentialing process, it also simplifies the payment process! You can find Aspirus Arise under WPS Health Solutions on the CAQH website.
EnrollHub™, a CAQH EFT/ERA Solution™, is a tool that allows physicians and other health care providers to sign up for EFT from multiple health plans or payers in one place, rather than enrolling individually with each payer. For a list of participating payers, including WPS Health Solutions, visit the
CAQH website
.
If you have questions about setting up an account or getting claims set up through EnrollHub, please contact CAQH directly. They are available 6 a.m. to 8 p.m. CT Monday through Thursday and 6 a.m. to 6 p.m. CT on Fridays.
CAQH Provider Help Desk:
If you have not yet set up an account, get started today to save time and get paid faster!
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Provider Portal Delivers Patient Eligibility and Benefits
Did you know our provider portal is a secure account that allows you to access subscriber and policy details through the
Patient Eligibility quick link? And because it is accessible 24/7, you aren't limited by standard business hours.
To verify patient eligibility, simply enter the minimum search criteria of:
- Subscriber ID + Date of Birth + Eligibility as of Date; or
- Last Name (partial name accepted) + Date of Birth + Eligibility as of Date; or
- First Name (partial name accepted) + Date of Birth + Eligibility as of Date
When you press the Search button, matching records are displayed. Click Patient name to see more patient details, including:
- Plan effective and termination dates
- Insurance entity
- Network name
- Copay
- Coinsurance
- Deductible
- Out-of-pocket balances
Information can be exported as a spreadsheet or PDF file by using icons in the upper right corner of your screen.
For complete instructions on how to use the functions of our provider portal, please see the
Provider Portal Overview on our website.
If you do not already have a provider portal account,
click here to register today!
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Provider Manual Revised for 2019
Please see our website for the
2019 Provider Manual. We review the manual annually to ensure accurate information is referenced. This year's revisions include updating the flow of the manual to make it more user-friendly and adding an explanation of the provider appeal process.
Our Provider Manual is designed and produced for our participating providers to promote a clear understanding of our policies and procedures, including:
- Prior authorizations
- Claims
- Eligibility
Participating providers are required to participate, cooperate, and comply with the program as outlined in this Provider Manual.
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Contact Us with Authorization Denial Notice Questions
If you have questions when you receive a denial notice for services, contact our Integrated Care Management team. You can reach out to the team by phone, fax, or in writing to review medical policy guidelines and/or discuss determination rationale.
The Integrated Care Manager (ICM) who initially reviewed the service can discuss the medical necessity denial decision and additional information on the reconsideration process. When indicated, the ICM will initiate the process for peer-to-peer discussion with a physician, appropriate behavioral health care specialist, or a pharmacist reviewer for a health plan customer under your care.
Contact us at:
Aspirus Arise Integrated Care Management
P.O. Box 11625
Green Bay, WI 54307-1625
Toll-free phone: 800-332-3297
Fax: 608-327-6300
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Medical Policy Guidelines Available
Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for an Aspirus Arise member under their care. Medical polices can be found on our website by clicking the Resources tab and selecting
Medical Policies. If you receive a determination and would like to review the medical policy guidelines used in that decision, you may contact us.
We also use 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 customer review through Integrated Care Management, submit your request via phone, fax, or in writing to:
Aspirus Arise Integrated Care Management
P.O. Box 11625
Green Bay, WI 54307-1625
Toll-free phone: 800-332-3297
Fax: 608-327-6300
Please include the subject (procedure/service/treatment) for the medical policy in question, along with the member 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, we can help you 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
[email protected] or send the request in writing to Aspirus Arise Integrated Care Management, Attention: Medical Policy Editor, at the address above.
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The Medical Policy Committee met March 15, 2019, 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. 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.
If you have specific questions or comments regarding development of policy, contact the Medical Policy Editor at
[email protected]
or 800-333-5003, ext. 78993.
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Medical Policies Up for Review
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
[email protected] or 800-333-5003, ext. 78993.
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.
Policies currently undergoing review with practicing providers and scheduled for committee discussion in the upcoming quarter include:
April
- Reduction mammoplasty (breast reduction surgery) for symptomatic macromastia
- Infertility and recurrent pregnancy loss testing and treatment
- Gender dysphoria treatment
- Non-covered services and procedures
May
- Back and nerve pain procedures-radiofrequency ablation, facet, and other injections
- Back pain procedures-epidural injection (caudal epidural, selective nerve root block, interlaminar, transforaminal, translaminar epidural injection
- Back pain procedures-sacroiliac and coccydynia treatments
- Non-covered services and procedures (necessary additions and deletions only)
June
- Ankle arthroplasty, total (total ankle replacement)
- Biofeedback treatments and devices
- Neuropsychological testing
- Urine drug/alcohol screening and testing
- Non-covered services and procedures
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Prior Authorizations Made Easy with iExchange®
If your organization hasn't already, now is the time to start using iExchange for your prior authorization requests. This FREE tool will benefit your organization and your patients by speeding up the prior authorization process. iExchange allows you to electronically submit prior authorization requests for inpatient and outpatient services directly to Aspirus Arise.
Using iExchange provides the following benefits:
- Automatic approval of specific requests
- Easy-to-use upload function for supporting documentation
- Status tracking of your requests
- Secure environment to safeguard Protected Health Information (PHI)
We are here to help support your organization's use of iExchange from the beginning. To sign up, follow these directions:
- Go to AspirusArise.com
- Click on the Providers link
- Choose the iExchange button
- Open up the Register for an Account section of the page
- Fill out the brief form and select Submit
We have
training videos
available on our website that explain how to register and use iExchange.
Once registered, the Account Administrator will be notified within 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 via email at
[email protected]
.
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Our Promise:
Make our high-quality health care services cost-effective
.
Integrate your health care so that your personal needs and preferences are considered.
Improve the communities we serve.
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