Dear Colleagues,
The COVID-19 pandemic has stressed our entire health care system. We at WPS Health Plan would like to extend a sincere thank you to all of the frontline physicians, nurses, and staff who continue to go the extra mile for their patients.
As we head into the winter months, we want to keep you apprised of the latest news regarding WPS Health Plan. In this issue, you can read about:
- Updates to our Prescription Drug Program
- Changes to our formulary
- The differences between appeals, reconsiderations, and corrections of claims
- The convenience of iExchange
- Updates to our CPAP/BiPAP authorizations
We are grateful for the care you provide to WPS Health Plan customers. If you have any questions, please contact me by email at Jonah.Fox@wpsic.com or by phone at 608-977-8038.
Sincerely,
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Jonah Fox, M.D., M.H.A.
Medical Director
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Prescription Drug Program updates go into effect Jan. 1
Information regarding our Prescription Drug Program can be found on our website. Specifically, you can access:
- Our Drug Program Policy, which includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits
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The Drug Prior Authorization List, which identifies the applicable medications as well as who to contact to initiate the process
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Specialty drug approval policies (see our Drug Prior Authorization Program page)
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The Formulary/Preferred Drug List
If you would like a copy of this information, please call our Provider Contact Center at 800-765-4977.
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Formulary/Preferred Drug List changes for Jan. 1, 2021* |
Preferred Drug List Exclusions with Alternatives**
Drug names listed in CAPITALS are BRAND NAME DRUGS. Drug names listed in lowercase are generic drugs.
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*May be subject to prior authorization requirements.
**WPS Health Plan has a pharmacy exception process. Exceptions must be approved in advance for coverage.
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Reminder: WPS Health Plan rebranding
We wanted to remind you that earlier this fall WPS rebranded Arise Health Plan, changing the name to WPS Health Plan. As we bring our brand more closely under the WPS umbrella, we are still committed to providing exceptional products and customer service.
Here’s a quick recap of what you need to know:
WPS Health Insurance
WPS Health Plan
- Formerly known as Arise Health Plan.
Dual-brand
- Reflected on our website and documents that are applicable to both insurance plans.
Please refer to your provider agreement(s) to determine whether you are participating in WPS Health Insurance, WPS Health Plan, or both. If you have any questions about which plan(s) you participate in, contact your Provider Relations Representative. Contact information can be found in the WPS Provider Manual.
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Practitioner and Facility Datasheets updated
Due to the recent rebranding of Arise Health Plan to WPS Health Plan, our Practitioner Datasheet and Facility Datasheet have been updated. Please discard any previous versions (dated prior to Oct. 2020) of these forms you may have on file and replace with the current versions.
Use of an outdated form may cause delays in the credentialing, contracting, and/or claims payment processes.
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Terminology rundown: reconsideration, appeal, or correction |
In an effort to ensure our providers receive appropriate avenues to submit disputes, we’ve added the Claims Reconsideration Request Form. In addition to this new form, we’ve revised the Provider Appeals Form to be more user-friendly.
Here are some things to keep in mind when completing a reconsideration, appeal, or correction request on a previously processed claim.
What is a claim reconsideration?
A reconsideration is a formal review of a previous claim reimbursement or coding decision.
When should you submit a Claims Reconsideration Request Form?
- The reimbursement amount is different than what the provider expected
- You have proof of timely filing of a claim denied for being late
- There is a dispute regarding Coordination of Benefits (COB)
What is an appeal?
An appeal is a written request to change an adverse initial claim decision. This can be due to noncompliance with prior authorization requirements, or services that are determined to be not medically necessary, or are experimental, investigational, or unproven.
When should you submit a Provider Appeals Form?
You should submit a Provider Appeals Form when you wish to challenge a decision or request an exception. The Provider Appeals form should only be completed in the following instances:
- Services were denied as not medically necessary, experimental, investigational, or unproven, when the provider submits clinical documentation to show that the services should not be denied as such
- A claim was denied for no authorization when the provider has an authorization number
- A claim was denied for lack of prior authorization, but the provider believes prior authorization should not be required due to extenuating circumstances
What is a corrected claim?
A corrected claim is a replacement of a previously submitted claim. A corrected claim is not a reconsideration or an appeal.
We encourage providers to submit new and corrected claims electronically. When submitting a corrected claim, use the appropriate Claim Frequency Type code to ensure your claim is noted as a correction. No additional form is required.
When should you submit a Corrected Claims Form?
When submitting a corrected claim via paper submission, you should use a Corrected Claims Form if the previously submitted claim requires a revision to coding, service dates, billed amounts, or customer information.
If you're not sure how your inquiry should be handled or where to send it, please contact our Customer Support department at 888-711-1444.
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Get the full benefits of the iExchange portal
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Did you know WPS Health Plan offers a FREE, FAST online service for providers to speed up prior authorization requests? Our iExchange online portal lets you securely submit prior authorization requests for inpatient and outpatient services directly to WPS 24 hours a day, seven days a week.
Benefits
- Direct, electronic submission that is secure, traceable, and less hassle than fax, paper, or phone
- Available when you are, not just during business hours
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Monitoring of request status in real time
- Attaching medical records is simple: no more waiting for fax confirmation
- Convenient communication with the WPS Medical Management team
- Maximize turnaround time, as your request will be in the system real-time
If you do not already have an account, registration is easy. Complete the required information and click submit. Within 10 business days, your administrator will receive an email with an assigned iExchange Group ID, User ID, and temporary password for you to access the tool.
Online training modules are a convenient way to get started. Please take a look! If you have questions, please email us at iExchange@wpsic.com. We are happy to answer your questions or coordinate training sessions with you and your staff.
Stay tuned as new features are coming in 2021! WPS Health Plan continues to review and monitor functionality as well as auto-approval guidelines and business rules in order to optimize your iExchange experience. We value your feedback. Please let us know what features would be most important to your organization by responding to iExchange@wpsic.com.
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Unlisted codes and prior authorization |
Keep in mind, claims received with an unlisted code undergo our Unlisted Code Review to ensure correct coding through our claims processing system. If a more appropriate code is identified, the claim may be denied, even with an approved prior authorization.
It is imperative that when you request a prior authorization, you submit the CPT or HCPCS code that accurately and precisely describes the services that are going to be provided. If no such code exists, then the appropriate unlisted code must be used. To ensure an accurate review of the request, provide as much information as possible, including:
- A detailed description of the diagnosis
- A detailed description of the procedure being requested
- Complete supporting clinical documentation for review
For additional information regarding prior authorizations, please visit our website or call our Intake Team at 800-333-5003.
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CPAP/BiPAP prior authorization changes |
Based upon provider feedback, we have streamlined our prior authorization process for Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) devices. As of Sept. 14, 2020, prior authorization is no longer required for CPAP and BiPAP rentals unless they extend beyond three months. CPAP and BiPAP purchases continue to require prior authorization, but can now be completed by phone.
To obtain prior authorization for a CPAP or BiPAP purchase, please call our Intake Team at 800-333-5003, option 4. In order for us to best assist you, please be prepared to provide the following information:
- Patient’s name
- Patient’s date of birth
- Patient’s ID number
- One of the following: last four digits of the patient’s Social Security number, patient’s address, or patient’s phone number
- Compliance information: the percentage the patient was compliant in using the machine at least four hours per night (minimum 60-day download required)
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Medical policy updates and review |
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The Medical Policy Committee recently met and approved the medical policies due for annual review.
Click here to view revisions to the 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.
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.
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 call 800-333-5003, ext. 06984.
Policies that will be reviewed in the upcoming months include the following:
January 2021
- Ankle Arthroplasty, Total (Total Ankle Replacement)
- Meniscal Allograft Transplantation
- Bone Growth Stimulators
- Biofeedback Treatments and Devices
- Neuropsychological Testing
- Deep Brain Stimulation and Responsive Cortical Stimulation
February 2021
- Artificial Disc Replacement
- Bariatric Surgery
- Blepharoplasty, Blepharoptosis Repair, Brow lift, and Related Procedures
- Corneal Treatments and Specialized Contact Lenses
- Shoulder Replacement
March 2021
- Non-Covered Services and Procedures
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- WPS will no longer allow consultation services, procedure codes 99241–99245 and 99251–99255, for any practice or care provider.
- The appropriate Evaluation and Management (E/M) procedure code which describes the office visit, hospital care, nursing facility care, home service, or domiciliary/rest home care service is reimbursable.
We also encourage providers to use the Claims Edit System® (CES) application available within our provider portal to view edit results and rationale that will be applied to specific code combinations. The CES application is available to all contracted providers through our provider portal. If you do not currently have a provider account, please complete a Request for Provider Access on our website.
For questions regarding medical coding related to policies, you may contact the Code Governance Committee at codegovernance@wpsic.com.
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Provider portal tips: claims search |
Did you know that our provider portal has information and tools to save you time? One such tool is the Claims Search feature. The Claims Search section in the provider portal allows providers to search for claims and view claim details and corresponding Provider Remittance Advice (PRA).
To search for a claim, use the Claims Search button under the Quick Links. On the Claims Summary page, you can search by claim timeframes, patient name, or account number. You can also search by check/EFT number by clicking the Advanced Search button.
When your search is complete you will see the following information for the claim(s) you requested:
- Claim Number
- Provider Name
- Customer ID
- Customer Name
- Date of Birth
- Date of Service
- Total Billed
- Status
- Check/EFT Number
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To see additional claims details including patient information, PRA, eligibility, and benefits, click on the Claim Number.
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If you do not have an account, register today to take advantage of this and other time-saving tools!
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HEDIS used for Quality Improvement |
We review and evaluate our Quality Improvement (QI) program each year and develop a QI work plan that helps us continually improve the quality of care given by our contracted providers. Our QI program and work plan include both clinical and quality service initiatives.
To evaluate program effectiveness, we use the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is developed and maintained by the National Committee for Quality Assurance (NCQA), a nonprofit health care quality organization.
Why is HEDIS important to physicians? HEDIS measures track a health plan's and physician's ability to manage health outcomes. Generally, strong HEDIS performance reflects enhanced quality of care. With proactive population management, physicians can monitor care to improve quality while reducing costs.
It's not just about the scores. It's about the woman whose pap smear led to early detection and treatment of her cervical cancer. Or the toddler who didn't get whooping cough because he received the appropriate scheduled immunizations. Or the 65-year-old who kept up with screenings that revealed increased cholesterol. As a result, he received appropriate treatment and potentially avoided another heart attack.
We look forward to working with you, our valued providers, during this upcoming HEDIS season. By working together to meet HEDIS benchmarks, we have the best chance of improving our customers' health outcomes and ultimately their quality of life. If you are interested in pursuing collaborative quality opportunities with us, please contact our Quality Department at qualityimprovement@wpsic.com.
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©2020 WPS Health Plan, Inc. All rights reserved. JO19049 |
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