The latest news for you

Spring 2022

Doctor's Note

Dear Colleagues,

In light of widespread immunity to COVID-19, the CDC recently updated the metrics on which it is basing its guidance on masking. The new metrics focus on hospitalizations and the impact of the virus on the health care delivery system, as opposed to infections alone.

As I write this note, more than 70% of Americans live in areas where wearing a mask is no longer recommended per the revised guidance. There are still exceptions to the relaxed guidance, including immunocompromised individuals, those at high risk for severe illness, and those who have contact with people at high risk for severe illness. While the current pandemic has made predicting the future a challenge, even for the experts, the most recent COVID-19 numbers and updated CDC guidance are good news, as the overall risk of severe illness associated with COVID-19 is lower.

Thank you for the care you provide to your patients and our customers. If you have any questions, please contact me by email at Jonah.Fox@wpsic.com or by phone at 608-977-8038.

Sincerely,

Jonah Fox, M.D., M.H.A.

Medical Director

More tips for the WPS ASO plans

You may see customers presenting a new ID card with the WPS Administrative Services logo. Be sure to bookmark the ASO Provider News page of our website for the most up-to-date information about our ASO plans.

If you can’t find the answer to your question on our website, please contact us at ProviderASOQuestions@wpsic.com. If you have questions related to specific customers, benefits, or claims, please call the customer service phone number on the customer's ID card or contact us through secure messaging via your provider portal account.

2022 Provider Manual available

The 2022 WPS Health Plan Provider Manual is available now on our website. In the manual, you can find details about our policies and procedures, including provider services, prior authorization, claims, and eligibility.

Also, please review the new reference guide for our enhanced ASO product. It outlines the differences between procedures for our ASO and fully insured business. We hope you find the guide and provider manual beneficial in answering any questions you have about WPS operations.

VIEW PROVIDER MANUAL

Call us for extensions on prior authorizations

Due to shortages of staff and beds, you may need an extension on recent prior authorizations. If you have a prior authorization in place with WPS but need to adjust it, please call us at 800-333-5003. We can help extend the end date of the authorization to allow you to begin or continue services.

iExchange makes prior authorizations easier

The days of faxing in your prior authorizations, hoping they were received, and getting no updates on their status are over. With iExchange, you get the answers you need faster than ever before. And that means your patients will receive better care.

Using the web-based iExchange tool speeds up the prior authorization process through:

Automatic approval of specific requests
Easy upload of supporting documents
Elimination of handwriting errors
Elimination of fax problems
Status tracking of requests
Secure environment for protected health information (PHI)

Want to begin using the iExchange web portal? Registration is easy. Within 10 business days, your administrator will get an email with an assigned iExchange Group ID, User ID, and temporary password for you to access the tool.

You'll have access to training tutorials that make using iExchange easy. Learn how to:

Get started
Add a submitting provider
Submit requests
And more

If you have any questions, need assistance with registration, or have technical issues, please contact our support team at iExchange@wpsic.com.

Did you receive a denial for an authorization? Our Integrated Care Management team is here to help.

You can speak directly to the Integrated Care Manager who reviewed the service. They will answer your questions, review medical policy guidelines, and/or discuss the reason the authorization was denied. You can also find out more about the reconsideration process.

If necessary, your Integrated Care Manager can arrange a peer-to-peer discussion with a physician, an appropriate behavioral health care specialist, or a pharmacist reviewer for a health plan customer under your care.

Contact our Integrated Care Management team:

Toll-free: 800-333-5003

Fax: 608-226-4777

Medical policy guidelines available

Physicians and other practitioners may obtain the medical policy guidelines used for making medical coverage determinations for a WPS Health Plan Insurance customer under their care. Medical Polices can be found on our website by clicking the Resources tab and selecting Support and Education. 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 Plan Integrated Care Management

P.O. Box 8190

Madison, WI 53708-8190

Toll-free: 888-711-1444

Fax: 920-490-6943

Please include the subject (procedure/service/treatment) for the medical policy in question, along with the customer’s 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 medical.policies@wpsic.com or send the request in writing to WPS Health Plan Integrated Care Management, Attention: Medical Policy Editor, at the address above.

Medical Policy updates and review

The Medical Policy Committee recently met 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 Health Plan Coverage Policy Bulletins on our website; no password required.

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 800-333-5003, ext. 06984.

Policies under review include:

April 2022 (effective Sept. 1, 2022)

Acupuncture Therapy
Cranial Orthotic Device
Hyperbaric Oxygen Therapy
Sleep Disorder Testing
Sleep Disorder Treatment: Positive Airway Pressure Devices and Oral Appliances
Whole Exome and Whole Genome Sequencing: NEW policy 2021

May 2022 (effective Sept. 1, 2022)

Back Pain: Sacroiliac and Coccydynia Treatments
Back and Nerve Pain Procedures-Radiofrequency Ablation, Facet, and Other Injections
Back Pain Procedures-Epidural Injection

June 2022 (effective Dec. 1, 2022)

Glaucoma Surgical Treatments
Infertility and Recurrent Pregnancy Loss Testing and Treatment
Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
Tumor Treating Fields (Alternating Electric Field Therapy)
3D Rendering of MRI/CT/US: NEW policy 2021

Utilization Management: making timely determinations

We know how important it is for you to get requested reviews. WPS uses these standards for our determinations:

Non-urgent pre-service decisions within 15 calendar days of receipt of the request
Urgent pre-service decisions within 72 hours of receipt of the request
Urgent concurrent review decisions within 24 hours of receipt of the request
Post-service decisions within 30 calendar days of receipt of the request

These time frames depend on the inclusion of necessary clinical information upon receipt of the request. We may request additional medical records if we need more information to make a decision.

If we cannot meet our standard deadlines, we notify the affected customer and requesting provider that an extension is necessary. We include the expected date of a decision in that notice.

We consistently strive to exceed these standards and meet the needs of our customers.

Navigating our Claims Editing Software

Did you know you can access our Claims Editing Software (CES) within our provider portal? With CES, you can enter code combinations and view results and rationales to ensure proper coding before you submit your claim.

To look up codes in CES you will need to access the provider portal. If you already have a username and password, choose Login. If you are new to the portal, select Register and in the drop-down choose WPS Health.

Once in the provider portal, select the Claims Editing System link under Extras on the Quick Links panel.

When you enter the CES, you will see this screen:

You can begin simulating code combinations by entering the gender, date of birth, and claim type under the Professional Claims Entry section. Please note that claim type defaults to Commercial. Enter all the applicable fields such as Begin Date of Service (Beg DOS), End Date of Service (End DOS), Procedure, Modifier, Diagnosis, Units, POS, Specialty, and Amount. Once you have entered all applicable fields, press the Submit button. Your results and rationale will be displayed. You can export these results as a PDF by selecting Export to PDF. To start a new code combination, click the New Claim button.

If you have any questions about coding and editing, contact our Code Governance Committee at codegovernance@wpsic.com. For assistance with understanding claims allowable, contact Provider Reimbursement at Provider.Reimbursement@wpsic.com.

ERA and EFT enrollment process moves to new platform

The WPS EDI is excited to announce a new partnership for Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT). We have completed the transition from CAQH EnrollHub to Change HealthCare (CHC) Payer Enrollment Services (PES).

With the new system, you will see shorter processing times for enrollments, fewer errors in processing, and improved customer service.

For more information and to enroll for electronic transactions, please visit the EDI webpage.

WPS partners with Hearing Care Solutions

WPS has teamed up with Hearing Care Solutions to offer customers free hearing exams and discounted rates for hearing aids. Customers who choose a Hearing Care Solutions provider will have access to this additional benefit. Those who choose a WPS contracted provider will continue to have access to the standard in-network benefits and pricing available through the network. To learn more about this partnership program, please contact Hearing Care Solutions at 303-407-6813 or visit hearingcaresolutions.com.

Member Rights and Responsibilities

The Member Rights and Responsibilities listed below set the framework for cooperation among covered persons, practitioners, and the insurer. This information is available on our website in the Customer Handbook.

Health plan customer rights:

The right to be treated with respect and recognition of dignity and the right to privacy.
The right to a candid discussion of appropriate or medically necessary treatment options for his/her conditions, regardless of cost or benefit coverage.
The right to participate with practitioners in making decisions about his/her health care.
The right to receive information about us, our services, our network of health care practitioners and providers, and the customer's rights and responsibilities.
The right to voice complaints or appeals about us or the care we provide.
The right to make recommendations regarding our customer rights and responsibilities policies.
The right to receive care according to federal and state mandates.

Health plan customer responsibilities:

The responsibility to supply information (to the extent possible) that we and our practitioners and providers need to provide care.
The responsibility to understand the customer's health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
The responsibility to follow the treatment plan and instructions for care that have been agreed upon with the customer's practitioners.
The responsibility to ask questions about the customer’s diagnosis, his/her treatment plan, and how to best manage his/her health.

Holiday closures reminder

Though our offices will be closed on the following dates in 2022, providers will still have access to benefits, patient information, claim status, and other key information via the provider portal.