Spring 2021

Doctor's Note Dear Colleagues,   At the onset of this pandemic, who could have predicted its duration and the severity of its impact on our lives and practices? As I write this message, three COVID-19 vaccines have been authorized and are in use, with more likely to come in the future. I know we all are anxiously looking forward to a gradual return to "normal." At WPS, we understand and are grateful for the role that you, as health care providers, play in battling this virus and caring for your patients and our customers. You were the heroes pre-pandemic, you are the heroes during the pandemic, and you will continue to be the heroes post-pandemic. In this issue, we have included updates regarding: Our Provider Manual Medical Policy guidelines Home sleep studies   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

Provider Manual updated A revised version of our Provider Manual is now available on our website. The Provider Manual is designed and produced for our participating providers to promote a clear understanding of our policies and procedures, including provider services, prior authorizations, claims, and eligibility. The manual has undergone format changes, the removal of redundant information, and streamlining of language. Also, links throughout the document have been updated to correspond to recent changes on our website.  Additionally, the Claim Payment Policies section now outlines claim resubmission, claim reconsideration, and provider appeals procedures. And on page 7, you can view a sample of the current customer identification (ID) card. As changes occur, our manual will be revised as appropriate throughout the year. When accessing the Provider Manual, please refer to our website for the most up-to-date information, policies, and procedures. 

COVID-19 updates Visit our website to keep up to date with the latest changes related to COVID-19.  Learn More

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 to all website visitors under Your Rights.   You have the right to: Be treated with respect and recognition of your dignity and your right to privacy. You also have the right to the privacy of your medical information unless you allow the release of such information. Participate in any decision-making regarding your health care. Have a candid discussion of appropriate or medically necessary treatment options for your medical condition. Receive the right care at the right level at the right time by the right type of provider for your medical condition. Receive information about preventive health care that is age- and gender-specific, and information about remaining as healthy as possible, including self-care and maintenance care for specific chronic diseases. Receive care according to federal and state mandates. Voice complaints or appeals about service from WPS Health Insurance or about care received.   You have the responsibility to: Provide, to the extent possible, information WPS Health Insurance and your physician or health care provider need to care for you. Be aware of your health care coverage and requirements/limitations under your certificate of coverage, including, but not limited to, precertification or prior authorization requirements and exclusions. Ask questions about your diagnosis, your treatment plan, and how to best manage your health. Follow the plans and instructions for care on which you have agreed with your physician or other health care provider.

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 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 Insurance Integrated Care Management P.O. Box 8190 Madison, WI 54308-8190 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, 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 Insurance 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. View the revised 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 Insurance Medical Policies List on our website; no password is 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 call 800-333-5003, ext. 06984.   Policies that will be reviewed in the upcoming months include the following:

April 2021 Acupuncture Therapy Cranial Orthotic Device Hyperbaric Oxygen Therapy Sleep Disorder Testing Sleep Disorder Treatment: Positive Airway Pressure Devices and Oral Appliances

May 2021 Back Pain: Sacroiliac and Coccydynia Treatments Back and Nerve Pain Procedures: Radiofrequency Ablation, Facet, and Other Injections Back Pain Procedures: Epidural Injection

June 2021 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)

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 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 provide additional information on the reconsideration process. When indicated, the ICM will facilitate the process for 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 us at: Toll-free phone: 800-333-5003 Fax: 608-226-4777

Home sleep studies Currently, providers can fast track their home sleep study via iExchange! There is a new questionnaire providers can complete while submitting a prior authorization request via iExchange, which can approve the home sleep study instantly. This short series of questions is used to establish the need for a home sleep study. When support for the study is confirmed, iExchange can then auto-approve the request. With the use of our iExchange questionnaire, you can quickly establish whether your patient/our customer can utilize their health benefits for coverage of these home sleep studies and schedule these studies much faster. For more information about iExchange and its use in home sleep studies, please email us at iExchange@wpsic.com.

iExchange makes prior authorizations easier Tired of using your old fax machine or relying upon the mail to complete your prior authorizations? For an easier and faster way to submit prior authorizations, use our iExchange online portal.   Using iExchange speeds up the prior authorization process, allowing providers to get the answers they need faster than ever before. A speedier process means your patients will receive better care.   Want to start using iExchange? 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.   Training modules on getting started, adding a submitting provider, and submitting requests can be found on our website.   If you have any questions, need assistance with registration, or have technical issues, please contact our iExchange support team at iExchange@wpsic.com.

Enhanced Find a Doctor application WPS Health Insurance recently enhanced our Find a Doctor application. The modified application is streamlined for ease of navigation when searching for preferred providers. To access the application, please visit our website and click Find a Doctor. The pop-up box (see below) will appear. Please select Start Your Search under the WPS Health Insurance heading to begin. If the subscriber is currently insured with WPS, select Existing Subscriber and follow the prompts. Note: a subscriber number is required.

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

Date of Closure Monday, May 31 Monday, July 5 Monday, Sept. 6 Thursday, Nov. 11 Thursday, Nov. 25 Friday, Nov. 26 Friday, Dec. 24 Holiday (observed) Memorial Day Independence Day Labor Day Veterans Day Thanksgiving Day after Thanksgiving Christmas Eve

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