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Doctor's Note
Dear Colleagues:
In this issue, you'll find a lot of helpful information plus tips to save you time. Please take a few minutes to review this newsletter.
There are articles on how to properly submit claims, how our RN Case Managers can help your patients, why coordination of care is important, and much more. My hope is that the information and links contained here will assist you in addressing the needs of your patients who have chosen Aspirus Arise coverage.
I have a deep appreciation for the work that you do, and we all thank you very much for the great service you provide to our members. I hope you find the information provided in this newsletter beneficial to your practice.
Best Regards,
Dr. Catherine Inman
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Dear Colleagues,
Over the last year, Aspirus Network (ANI) has made tremendous progress closing gaps in care and moving to a more patient-centered, integrated system of health care delivery, which includes Aspirus Arise.
As ANI continues to collaborate with Aspirus Arise as our health insurance partner, our goal is to focus on:
- Supporting the needs of patients via an extended care team model
- Improving patient engagement and self-management skills by maximizing involvement of the total health care team
ANI has had success working with Aspirus Arise to identify gaps in care on a patient-by-patient basis. This effort has resulted in getting patients scheduled for appointments that give ANI providers the opportunity to address previously untreated conditions.
ANI and Aspirus Arise team members continue to work together to develop strategies that encourage patients with gaps in care to see their providers, and to provide appropriate notification to the care team. This effort includes working with clinic and regional leadership to integrate this information into existing workflows. By refining the identification process, we anticipate better detection of gaps in care. We are also working to efficiently convey actionable information to increase the overall quality of care provided.
While addressing gaps in care is the right thing to do for our patients, the actions taken also have financial implications for Aspirus Arise. Regulations are in place to dissuade health plans from solely focusing on utilization reduction activities. These regulations provide financial incentives to health plans that successfully identify specific gaps in care and treat the conditions.
Please continue to provide feedback to help us improve these processes. The quality of care we provide and our overall financial stability rely on providers taking action to help close gaps in care for their patients.
Sincerely,
Dr. Renee Smith
Renee Smith, MD
Executive Director and Chief Medical Officer
Aspirus Network Inc.
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Use iExchange to Complete Prior Authorization Requests Faster
Aspirus Arise offers a FREE online service to speed up your prior authorization requests. It's called iExchange. This tool allows you to electronically submit prior authorization requests for inpatient and outpatient services to us 24 hours a day, seven days a week. There are many benefits of using iExchange, such as:
- 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)
If you are not already registered, it's easy to sign up:
- 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
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
iExchange@wpsic.com
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Our RN 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
- Explaining their health insurance benefits
- Assisting them to become better health care consumers
Our Health Resource Team members are RN's who 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 Health Resource Team members made a difference for a patient like yours. A health plan member with a history of transplant was trying to manage chronic low back pain. The individual did not want to take pain medications due to the transplant history, and was getting more and more frustrated when unable to find instant relief after seeing multiple in- and out-of-network providers. The person was searching online for experimental treatments and cures, but did not understand the risks or potential financial impact of trying experimental treatments.
An RN on the Health Resource Team reached out to this member and took the time to get to know the member's concerns. Through these conversations, the Health Resource Team RN was able to help the member understand the risks of experimental treatments, as well as understand the importance of communicating concerns and questions to a provider and working with the provider to develop a treatment plan to meet the person's needs. Our Health Resource Team RN built a trusting relationship with this member and helped the member find an in-network orthopedic provider who helped deliver a successful outcome.
We are here and ready to help your patients. If you have a patient you feel might benefit from the Health Resource Team's services, please contact Aspirus Arise at
715-843-1061
to speak with a member of the Health Resource Team or email
CDMHRT-AspirusInc-Intake@aspirus.org
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Notify Us of Inpatient Hospital Admissions
We require notification of a member's urgent/emergent hospital admission within 48 hours of admission. Immediate notification is best to help facilitate timely medical necessity reviews, inpatient stay authorizations, and claims processing.
When notification is not received, there is no medical necessity review completed and no authorization in place, which results in denied claims. We want to work with hospitals to ensure processes on both sides can be completed efficiently.
The most convenient and efficient way to notify us of a member's inpatient admission is online through iExchange. This online portal lets you send the information directly to us 24 hours a day, seven days a week. You can also attach medical documentation for the required medical necessity review through iExchange, helping with quicker turnaround times for reviews and authorizations.
Notification of inpatient admissions can also be done by phone at 800-332-1412 or by fax at 608-327-6300.
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Sometimes a claim is submitted but cannot be processed/entered into our system because it is not a "clean claim." 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, and has no substantial issue regarding the insurer's responsibility for payment, including, but not limited to, subrogation or coordination of benefit issues.
Clean claims must be submitted using:
- Current HIPAA standard professional or institutional claim formats for electronic claims, as applicable; or
- Current UB-04 and CMS 1500 forms (or any successor forms) for paper claims; and accepted coding standards
If a claim does not meet the criteria as a clean claim, you will receive notice. That notice will consist of a 277CA electronic transaction for electronically submitted claims. If the claim submission was on paper, you'll receive a letter. When resubmitting a claim, please resubmit as a new claim using submission type 1. While no
Corrected Claim Form
is required, it is essential the resubmitted claim meets the clean claim criteria listed above.
Sometimes a processed claim needs to be resubmitted because there was an error on the original claim that needs correction. When resubmitting electronically, be sure to use the correct Claim Frequency Code (billing code) of 7 for a replacement/correction or 8 to void a prior claim. Don't forget to enter the original claim number in the 2300 loop in the REF*F8*. If submitting on paper, the
Corrected Claim Form
must accompany your resubmission. Please complete the form in its entirety.
The easiest way to remember whether a Corrected Claim Form is required is that claims returned to you with no claim number don't need the form when resubmitted. Claims assigned a claim number on a Provider Remittance Advice (PRA) or Explanation of Benefits (EOB) do require the corrected Claim Form when they are resubmitted.
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Do You Want to get Paid Faster?
Enroll for Electronic Funds Transfer (EFT) to receive your payments via direct deposit to your bank account!
Electronic claim filing (EDI) and electronic remittance advice (ERA) are also available at no cost.
If you have any questions regarding EDI, ERA, or EFT, please contact our dedicated EDI team at
800-782-2680, option 2.
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Focus on Flu Vaccine
The season is upon us: fall, football, and flu vaccine. The 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!
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Quarterly Medical Policy Updates
The Medical Policy Committee met this quarter and approved the medical policies due for annual review. The policy updates were emailed to providers in July and we have included them in this issue for your convenience.
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.
Specific questions or comments regarding development of policy content may be directed to the Medical Policy Editor
medical.policies@wpsic.com
or 800-333-5003, ext. 78993.
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Additional Medical Policies for Review in September 2018
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 medical.policies@wpsic.com 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 include:
- Corneal Treatments and Specialized Contact Lenses
- Glaucoma Surgical Treatments
- Intraoperative Neurophysiologic Monitoring
- Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
- Magnetic Resonance Spectroscopy (MRS), Nuclear Magnetic Resonance Spectroscopy (NMRS)
- Microprocessor-Controlled and Myoelectric Limb Prosthesis
- Noncovered Services and Procedures
- Omnibus Pharmacy Policy for Treatments Reviewed by Medical Affairs
- PET Scan (Positron Emission Tomography)
- Sleep Disorder Testing
- Sleep Disorder Treatment
- Stereotactic Radiotherapy-SRT
- Varicose Vein Treatments
- Vision Therapy (Orthoptic Training, Orthoptics, Pleoptics)
- Wearable Cardiac Defibrillator
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Our Promise:
Make our high-quality health care services cost-effective
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Integrate your health care so that your personal needs and preferences are considered.
Improve the communities we serve.
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