Doctor's note

The Centers for Disease Control and Prevention (CDC) has officially declared the end of the COVID-19 public health emergency, effective May 11, 2023. 

You and your patients may notice some changes to WPS health coverage. After May 11:

• Over-the-counter COVID-19 tests will not be covered.
• COVID-19 vaccines will be covered as preventive services.
• Doctor-ordered COVID-19 tests and treatment will be covered according to the language and benefits in the patient's policy.

If you have questions about changes to WPS health coverage, please visit the WPS Provider page.

Of course, the end of the public health emergency doesn't mean the end of COVID-19. We know you will continue to see COVID-19 cases among your patients, and the CDC will continue to monitor the metrics. We will keep you up-to-date on any other upcoming changes.

We thank you for your commitment to the treatment and management of these cases during the past three years and for your continued diligence.

In addition to addressing the end of the pandemic, this edition of the newsletter includes important information about:

• WPS Powered By Auxiant™ logo
• Zelis Payments^® to be used on all plans
• Updates to virtual care policy
• Which form to use for appeals, claim reconsiderations, or claim corrections

We appreciate all you do in caring for your patients. If you have any questions, please contact me by email at Kevin.Rak@wpsic.com.

Kevin M. Rak

Medical Director

WPS Health Insurance/WPS Health Plan

WPS Powered By Auxiant^™ has a new logo

WPS Powered By Auxiant has a new logo for our self-funded members. We are not reissuing new cards to existing accounts at this time. Thus, you will see the old and new logo on the customer ID cards.



Member, benefit, and claim submission information on the cards has not changed.

All WPS plans to begin using Zelis^® Payments

Beginning in 2021, WPS began using Zelis Payments for our Administrative Services Only (ASO) and certain fully insured plans. Effective September 2023, WPS will expand its use of Zelis Payments for all WPS commercial insurance plans. Streamlining the automated clearinghouse (ACH) and electronic remittance advice (ERA) delivery processes for all plans will simplify our processes.

The table below outlines what you can expect based on your relationship with Zelis for this upcoming change.

Virtual care policy

Telehealth services have provided valuable access and care to our customers and your patients throughout the pandemic. With the expiration of the COVID-19 Public Health Emergency, WPS has implemented the Virtual Care Policy, which replaced the Temporary Telehealth Policy. You can find a copy of this policy and others on our website under Resources > Provider Resources > Support and Education > Reimbursement Policies.

If you have questions regarding medical coding related to policies, please email the Code Governance Committee at codegovernance@wpsic.com.

For questions regarding the policies outside of medical coding, please email Provider.Reimbursement@wpsic.com.

Which form should I use: Corrected Claim, Reconsideration, or Provider Appeal?

WPS has different processes and forms for submitting a corrected claim, reconsideration request, or appeal. Below is a quick reference guide to help you determine which form to use for each.

When should you submit a Corrected Claim Form? 

A corrected claim is a replacement and/or correction of a previously submitted claim. It is not an inquiry or an appeal. We encourage providers to submit new and corrected claims electronically, but they can be submitted by mail or faxed to 608-327-6332. 

When submitting a corrected claim electronically, use the appropriate Claim Frequency Type code to ensure your claim is noted as a correction. No additional form is required.

When submitting a corrected claim via paper submission, you should use a Corrected Claim Form if a previously submitted claim requires a revision to any of the following:

• Coding
• Service dates
• Billed amounts
• Member information

Corrected claims must be submitted within six months of the original claims process date.

When should you submit a Claims Reconsideration Request Form?

A reconsideration is a formal review of a previous claim reimbursement or coding decision. You should submit a Claims Reconsideration Form when you believe a claim was paid incorrectly. Situations appropriate for use of the Claims Reconsideration Form include when:

• The reimbursement amount is different than expected
• You have proof of timely filing of a denied claim
• There is a dispute of Coordination of Benefits (COB) information

Claims reconsiderations must be submitted within six months of the original claims process date. 

To initiate the Provider Appeal process, the Provider Appeals Form must be completed in its entirety.

You have up to 60 days from the date of claim processing to submit a provider appeal.

Using the appropriate form for each process will help avoid delays and allows us to respond to your request more quickly. Copies of all three forms are available on our website under Resources > Provider Resources > Forms and Documents.

The advantages of using Electronic Data Interchange (EDI)

WPS encourages health care providers to file their claims electronically whenever possible. Electronic filers receive these benefits:

• Faster claims processing. Providers who file claims electronically receive payment sooner than if they had filed the same claim on paper.
• Reduction of payment errors and data entry errors. As a result of WPS' pre-edits for EDI, claims that pass to the processing system pend less frequently. This means there is less potential for processing errors.
• Immediate verification of claims received. All of WPS' verification reports provide vital feedback at each stage of the EDI processing cycle. This feedback is not present with paper claim submission. After transmitting your claims to WPS, you receive a verification notice via email indicating the number of claims and dollar amount we received. Also, an "Error Report" will be available the business day following your transmission. This report indicates whether any claims were submitted with errors and what changes need to be made for claims to be accepted for processing. These claims can be corrected and resubmitted electronically.
• EDI program edits minimize the impact of data entry errors at your office by requiring certain information to be entered on your claims.
• Relative ease of use of EDI. Support is available from the contractor to assist you in beginning use of EDI transactions.
• Lower administrative, postage, and handling costs.
• Availability of free software.
• Availability of batch claims status inquiries.
• Shorter payment floor. Payment floor for Medicare claims is 14 days for electronic versus 30 for paper.

Need to register for the provider portal?

Medical Policy updates and review

The Medical Policy Committee recently met and approved the medical policies due for annual review. 

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 Insurance/Health Plan Policy Updates 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 that will be reviewed in the upcoming months include:

NIA Magellan becomes part of Evolent Health, LLC

Have you heard? Magellan transferred ownership to Evolent Health, LLC. As a result, National Imaging Associates (NIA) will now be a subsidiary of Evolent Health, LLC.

Evolent Health, LLC has completed the acquisition of NIA Magellan as of January 2023. As a result, the names NIA Magellan and Magellan Specialty Health are consolidated under Evolent Health, LLC (Evolent):

• Phone numbers
• Fax numbers
• Customer logos and branding (NIA only)
• Contact information in letters

Utilization Management follows timeliness standards

WPS adheres to the following timeliness standards for review of requested services. The time frames include:

• For nonurgent pre-service decisions, WPS makes decisions and notifies the practitioner and customer (via written or electronic notification) within 15 calendar days of receipt of the request.
• For urgent pre-service decisions, WPS makes decisions and notifies the practitioner and customer (via written or electronic notification) within 72 hours of receipt of the request.
• For urgent concurrent review, WPS makes decisions and notifies the practitioner and customer (via written or electronic notification) within 72 hours of receipt of the request.
• For post-service decisions, WPS makes decisions and notifies the practitioner and customer (via written or electronic notification) within 30 calendar days of receipt of the request.

These time frames are dependent on the inclusion of necessary clinical information upon receipt of the request. We may request additional medical records if the information submitted is not sufficient.

If we cannot decide by our standard deadlines, we notify the affected customer and requesting practitioner that an extension is necessary. The date we expect to make a decision is included in that notice.

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

Case Management for pregnant customers

WPS designed its Case Management to empower our customers. Through Case Management, customers can learn about their conditions, helping them manage their own symptoms, control health care costs, and improve their health. 

Registered Nurse Case Managers help customers achieve these goals by:

• Coordinating health care between providers
• Providing education regarding their health care needs and concerns, improving health care literacy
• 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 RN Case Managers 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’s one recent example. One of our Case Managers reached out to a newly pregnant mother. In working with this customer, the Case Manager learned that our customer had vasa previa (unprotected blood vessels that travel across the cervical opening). The Case Manager helped the customer create a pregnancy plan that would allow the customer to be admitted for inpatient monitoring for the planned four weeks prior to delivery. Working in advance on this pregnancy plan allows for a seamless admission to the hospital as the customer has a planned cesarean section. The customer reported a noted decrease in her anxiety around this admission because she had been working with the health plan prior to delivery. 

During their outreach, our Case Managers often connect with expecting mothers that could be considered high-risk. Through Case Management, we help customers better understand their health care benefits, help them manage their personal health care needs during pregnancy, inform them of community and technical resources that can help meet their needs, and support optimal maternal and infant outcomes. If you are interested in referring a patient to our Maternity Program, click here.

Coordination of care between behavioral health

and primary care practitioners

Patients benefit when providers coordinate care on treatment planning and ensuring appropriate diagnosis, treatment, and referral. Coordination of care is an essential part of the process, not just for specialists, but for primary care practitioners (PCPs) and behavioral health practitioners.

We expect all health care practitioners to have a mechanism in place to:

• Discuss with the customer the importance of communicating with other treating practitioners
• Obtain a signed release from the customer and file a copy in the medical record
• Document in the medical record if the customer refuses to sign a release
• Document in the medical record if you request a consultation
• If you made a referral, transmit the necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner

All health care practitioners must also document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

With this collaborative approach, we can achieve excellent coordination of care and help improve health outcomes.

Utilization Management vendor change reminder

WPS has partnered with Express Scripts, Care Continuum, and eviCore Healthcare to provide prior authorization services for select specialty drugs and oncology utilization management (UM):   

• eviCore manages authorizations for medical oncology and radiation oncology services.
• Care Continuum manages authorizations for specialty medical drugs.
• Express Scripts manages authorization for non-oncology pharmacy drugs (including specialty pharmacy drugs).

You can find drugs subject to prior authorization on the WPS Drug Prior Authorization List.

Medical Oncology/Radiation Oncology

• Vendor: eviCore
• Phone: 800-475-1954 (option 3)
• Fax: 800-540-2406
• Provider portal (preferred submission): eviCore.com

Medical Drugs (for non-oncology)

• Vendor: Care Continuum
• Phone: 800-475-1954 (option 2)
• Fax: 833-933-2367
• Provider portal (preferred submission): eviCore.com (will be triaged to Express Scripts OnePA)

Pharmacy Drugs (for non-oncology)

• Vendor: Express Scripts
• Phone: 800-475-1954 (option 1)
• Fax: 833-933-2367
• Provider portal (preferred submission): Through the provider's preferred ePA portal:
• Surescripts^® providerportal.surescripts.net/ProviderPortal/login
• CoverMyMeds^® covermymeds.com/main/prior-authorization-forms/express-scripts
• ExpressPAth^® express-path.com/login.aspx

*NOTE: For pharmacy drugs, if an ASO group is using a PBM other than Express Scripts through WPS, refer to the other PBM.

Specialty pharmacy vendor change reminders

WPS has also partnered with Accredo^® Specialty Pharmacy as our preferred specialty drug pharmacy. To submit a prescription referral:

Electronically

• You can use Accredo’s prescriber website MyAccredoPatients.com. Simply register or log in and navigate to Send a Referral on the dashboard. Once you log in, you will be routed to iAssist, which is Accredo's electronic referral service. If you are not registered for iAssist, you will be prompted to do so.

Fax

• Visit accredo.com and select Prescribers at the top of the page and then Referral Forms. You can choose referral forms by product or therapy name, or by the first letter of the specialty condition. Then, fill in the required prescription and enrollment information and fax it to the number printed on the form.

Phone

• You can also contact Accredo at 866-759-1557. Representatives are available from 7 a.m.-7 p.m. CT, Monday–Friday.

We appreciate your support with the vendor changes. If you have questions about the changes, please contact the WPS Provider Contact Center at 800-765-4977.

Holiday closures reminder

Even though our offices will be closed on the following dates, you can still access benefits, patient information, claim status, and other key information via our provider portal.

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