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Doctor's note
As a physician who has practiced medicine for more than 13 years, I can relate to the demands of your daily workload. I understand and appreciate the time it takes to evaluate, discuss, and document your patient encounters.
I value your time and want to take this opportunity to introduce this month's Spring 2018 newsletter issue. Our goal is to provide information and links to assist you in addressing the needs of your patients with Arise Health Plan. These links will allow you access to our medical policies and the quarterly updates.
Thank you very much for the great service you provide to your patients, who are our customers, and I hope you enjoy the convenience of and information provided in this newsletter.
Best Regards,
Dr. Catherine Inman
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When is prior authorization needed?
We require prior authorization for inpatient stays and select specialized outpatient services. Please refer to the
Arise Prior Authorization List,
which we update regularly on our website. You may find helpful tips for filing prior authorization requests in our
Arise Prior Authorization
section.
If you are unclear if a service will be covered or requires prior authorization, please contact Customer Service by calling 888-711-1444 or through the Message Center in our Provider portal.
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Contact us with authorization denial notice questions
If you would like to review medical policy guidelines and/or discuss determination rationale when you receive a denial notice for services, you may contact the Integrated Care Management team in our Medical Affairs Department via 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 care specialist, or a pharmacist reviewer for a health plan customer under your care.
Contact us at:
Arise Health Plan Integrated Care Management
P.O. Box 11625
Green Bay, WI 54307-1625
Phone: 920-490-6901
Toll-Free Phone: 888-711-1444, ext. 76901
Fax: 608-327-6300
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Medical policy guidelines available upon request
Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for an Arise Health Plan customer under their care. If you receive a determination and would like to review the medical policy guidelines used in that decision, you may contact us.
Arise also uses 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.
Arise Health Plan Integrated Care Management
P.O. Box 11625
Green Bay, WI 54307-1625
Phone: 920-490-6901
Toll-Free Phone: 888-711-1444, ext. 76901
Fax: 608-327-6300
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, 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 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 Arise Health Plan Integrated Care Management, Attention: Medical Policy Editor, at the address above.
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Use EDI Express Enrollment (E3) for fast enrollments
WPS Health Solutions has implemented a new online enrollment process called EDI Express Enrollment (E3). E3 streamlines the WPS electronic data interchange (EDI) online enrollment process. Take a look at some of the benefits of using E3:
- Most enrollments can be completed in one web session in less than five minutes.
- E3 guides you through the enrollment process using simple questions.
- Based on your answers, E3 generates the necessary agreement(s) and auto-populates the information onto each agreement so you can electronically sign them during your web session.
- Information provided in the enrollment is validated in real time, so we'll let you know if incorrect information is entered as you enroll. This eliminates delays in your enrollment.
- No more uploading agreements!
Our previous EDI enrollment system, Formvine, is no longer being used. If you are not currently using E3, please visit our website at:
wpsic.com/edi/edi-forms.shtml
.
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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 Jan. 31, 2018, and we have included them in this issue for your convenience
.
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
[email protected]
or 800-333-5003, ext. 78993.
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Medical Policies up for review in June 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
[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 whenever you see it.
Policies currently undergoing review with practicing providers and scheduled for committee discussion in June include:
- Artificial disc replacement
- Back and Nerve Pain Procedures: Radiofrequency ablation, facet, and other injections
- Back Pain Procedures: Epidural injections
- Back Pain: Sacroiliac and coccydynia treatments
- Cochlear implants and bone-anchored hearing aids
- Hyperbaric oxygen therapy
- Infertility testing and treatment
- Total ankle arthroplasty
- Treatment of gender dysphoria
- Non-Covered Services and Procedures: updates are reviewed on a quarterly basis
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Medicare clinical lab rates now national
There has been a change in the composition of the Medicare Clinical Lab Schedule. In previous years, Medicare had established rates by state for lab services. As of January 2018, Medicare will only provide one national rate. All state rates are converted to the national rate in 2018.
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