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Doctor's note
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 at WPS.
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 WPS. 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
- Newsletter scheduling changes
- 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.
Jonah Fox, M.D., M.H.A.
Medical Director
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New credentialing partner
Our Credentialing Department has contracted the services of Ideal Privileges LLC, dba Eddy to work with our company in the capacity of a Credentials Verification Organization (CVO).
A CVO collects application materials and performs primary source verifications of application information. Once Eddy verifies the application is complete, the company will return it to our Credentialing Department to complete the credentialing approval process.
Contracted practitioners may receive requests from Eddy for information needed to support their credentialing for the WPS provider panel. Outreach may come in the form of an email from
[email protected] or a phone call from an Eddy employee. These requested materials should be returned directly to the CVO. There are no other changes to our credentialing process.
Practitioners should continue to complete our
Practitioner Datasheet found on our website. Please return as directed on the form to report any practitioner adds, terminations, or changes to rosters or locations. The WPS Credentialing Department will make initial contact with the practitioner to initiate any required credentialing and will authorize Eddy to begin the process. Please DO NOT contact Eddy directly for an application and DO NOT use any old application templates you may have kept on file. Practitioners currently using CAQH may continue to do so; please be sure to keep your CAQH record up to date with current attestation and documentation. Those practitioners that do not wish to use CAQH will receive directions as to how to access an online credentialing application.
Our Credentialing Department is confident this arrangement will help us maintain efficient application turnaround times so practitioners are able to see our customers as quickly as possible. If you have any questions regarding the credentialing process, please contact us at [email protected].
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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 customers is one of the most important public health activities we can support.
Two of the primary barriers that prevent our customers 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 customers 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 customers 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, they also simplify the payment process!
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. You can find Arise under the WPS Health Solutions reference.
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.
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Provider Manual revised for 2019
Revisions include updated contact information and the provider appeal process. Our Provider Manual is designed and produced for our preferred providers to promote a clear understanding of our policies and procedures, including:
- Prior authorizations
- Claims
- Eligibility
Preferred 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.
WPS Health Insurance Integrated Care Management
P.O. Box 8190
Madison, WI 53708-8190
Toll-Free Phone: 800-333-5003
Fax: 608-226-4777
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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 a WPS Health Insurance customer under their care. Medical polices can be found on our website by clicking the
Providers tab and selecting
Medical Policy. 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:
WPS Health Insurance Integrated Care Management
P.O. Box 8190
Madison, WI 53708-8190
Toll-Free Phone: 800-333-5003
Fax: 608-226-4777
Please include the subject (procedure/service/treatment) for the medical policy in question, along with the customer name and customer 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 customer'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 WPS Health Insurance Integrated Care Management, Attention: Medical Policy Editor, at the address above.
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Case Managers can make a difference for your patients
Our RN Case Managers are here to help our mutual customers by:
- Coordinating health care between providers
- Providing education regarding their health care needs and concerns
- Supporting and advocating for improved health care experiences and outcomes
- Locating available community resources
- Understanding their health insurance benefits
- Assisting them to become better health care consumers
Our RN Case Managers work one-on-one with your patients, treating each person as an individual with unique needs and challenges. Through confidential conversations, they get to know your patients and assist each one to overcome challenges affecting their health management and care.
Here is an example of how one of our Case Managers made a difference for a patient like yours.
A 37-year-old man with a history of a cardiac arrhythmia was unhappy with his cardiologist. He was frustrated when he was still symptomatic after having a procedure. He wore a monitor for 30 days but was never provided the results. The man chose to see a new cardiologist, but this new cardiologist needed to see the results from the 30-day monitoring.
This is where our Case Managers were able to assist with the communication between providers, while assessing the customer's needs and concerns. The Case Manager called both providers, and was able to forward the monitoring results to the new cardiologist. Once the new provider received the results, he was able to develop a great working relationship with the customer, discussing possible treatment plans and procedures.
The personal phone call encouraged the customer and built trust with the provider. Soon after the customer underwent another procedure for his cardiac arrhythmia, which was successful.
After the procedure, the customer called the Case Manager and said, "I can't remember when I have ever felt this great." The customer's quality of life improved because of effective communication between our Case Manager and the providers, enabling the customer to have the needed procedure so quickly.
We are here and ready to help your patients. If you have a patient you feel might benefit from Case Management services, please contact Medical Management at 800-333-5003 and ask to speak with a Case Manager or email [email protected].
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Medical policy updates
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.
The complete library of our medical policies can be found at
WPS Medical Policies
on our website; no password required.
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 WPS.
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 wpshealth.com
- Click on the Resources link and, under the Provider Resources heading, select iExchange
- Click Register
- Fill out the brief form and select Submit
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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WPS Health Insurance | 1717 W. Broadway | Madison, WI |
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©2019 Wisconsin Physicians Service Insurance Corporation. All rights reserved. JO14997
33707-100-1904
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