Summer 2021

Doctor's Note Dear Colleagues,   As I write this message, the United States is averaging fewer than 30,000 new COVID-19 cases per day for the first time in almost a year. Additionally, 1.8 million daily vaccinations have been administered on average over the past week, with roughly half of the population having received one shot or more. While we all know that the pandemic isn’t over, we are hopeful for what the future may bring. Small pieces of “normal life” are slowly beginning to return, and none of this progress could have been possible without your courage and dedication to serving your patients and communities.   In this issue, we have included updates regarding: Your guide to WPS rebranding Provider appeals procedures Our case management programs Diabetes and Respiratory Population Health Management programs   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

Your quick guide to WPS rebranding Confused by the newly rebranded WPS Health Plan (formerly Arise Health Plan)? We’ve got you covered! Here’s a snapshot of the branding changes to WPS Health Insurance and WPS Health Plan.

How to choose the right provider appeal form When submitting provider appeals, corrected claims, and claim reconsideration requests, please make sure to select the correct form and send your request to the appropriate address. Correspondence submitted without a form or with the incorrect form may be returned to you for resubmission.    Use the Provider Appeal Form if your claim is denied for one of the following reasons: Prior authorization was not obtained Services are considered not medically necessary or experimental/investigational/unproven   Use the Claims Reconsideration Request Form (reconsideration of initial claims processing) for any of the following disputes: The reimbursement amount is different than what was expected You have proof of timely filing of a claim denied for being late There is a dispute regarding Coordination of Benefits (COB) information   Finally, use the Corrected Claims Form (revision needed to original claim submitted) for any of the following reasons: Corrected diagnosis Corrected date of service Corrected charges Corrected patient or provider information Addition or correction of a modifier   Claim Reconsideration Request Forms and Corrected Claims Forms should be mailed to the following address:   WPS Health Solutions P.O. Box 21341 Eagan, MN 55121    If you're not sure how your inquiry should be handled or where to send it, please contact our Customer Service department at 888-711-1444.

Our mailing address for provider appeals has changed We recently updated the mailing address for submission of provider appeals to the following address:   WPS Provider Appeals P.O. Box 7062 Madison, WI 53707-7062   To ensure timely processing of your appeal, we ask that you discard any previous versions of the form you have on file and replace with the current version. Effective July 1, 2021, we will only accept the current Provider Appeal Form for processing your appeal.

Coordination of care between behavioral health and PCPs is crucial Coordination of care among providers is a vital aspect of good treatment planning, helping to ensure appropriate diagnosis, treatment, and referral. The importance of communicating with a customer's other health care practitioners cannot be overstated. This includes primary care practitioners (PCPs) and medical specialists, as well as behavioral health practitioners.   Coordination of care is especially important for customers with complex medical care needs and those referred to a behavioral health specialist by another health care practitioner. All practitioners should obtain the appropriate permission from these customers to coordinate care among behavioral health and other health care practitioners at the time treatment begins.   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 necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner 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.

Case Managers can make a difference for your patients WPS Case Management is designed to educate and help customers self-manage their symptoms, control health care costs, and improve their health. RN Case Managers help achieve these goals by: Coordinating health care between providers Providing education regarding their health care needs and concerns (improve 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. In April of 2021, our Case Manager reached out to a customer who was recently discharged from the hospital after he had a blood clot surgically removed from his leg. When our Case Manager assessed his current needs, this customer didn't have enough dressing to last for the duration of his wound care. The customer explained that the local pharmacies did not have this bandaging and he was unsure what to do. In working with his RN Case Manager, he was able to reconnect with the team that performed the surgery to obtain more supplies, allowing him to continue his wound care. In another situation, our RN Case Manager reached out to a customer after his hospitalization for surgical removal of a mass in one of his lungs. The customer was distraught because the provider supplying his oxygen could not verify his insurance coverage. The RN Case Manager contacted the provider and the customer received the oxygen the very same day. In a follow-up call, the customer said, “I can't thank you enough. (The oxygen) helped me tremendously last night.” Our Case Management team is here and ready to help your patients. If you have a patient who you feel might benefit from Case Management Services, please contact Medical Management at 800-333-5003 and ask to speak with a Case Manager, or email WPSHI.Case.Management@wpsic.com.

Take advantage of WPS population health management programs Did you know that WPS Health Plan has a population health management program for Diabetes and Comorbidity and one for Respiratory issues? These programs provide customers with education, resources, and assistance such as: Helping customers understand the importance of following up with their primary care practitioners or specialists after emergency room or urgent care after diabetic and comorbidity and respiratory-related visits. Helping customers learn how to better manage their medical conditions by taking their prescribed medications correctly, creating a personalized action plan to discuss with their providers, eliminating or reducing environmental triggers, and incorporating active, healthy lifestyles. Providing customers with smoking cessation support and education regarding available community and online resources as well as no-cost smoking cessation products available through their health plans. Providing education to customers to help ensure they have the supplies and diabetes-related checkups they need to manage their diabetes properly. If you have a patient that you feel would benefit from the population health management programs for Diabetes and Comorbidity or Respiratory issues, please call 800-333-5003. Our Population Health Management staff and Registered Nurse Case Managers are eager to help.

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 Plan 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 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:

July 2021 Effective Dec. 1, 2021 Capsule Endoscopy Cell-Free Fetal DNA Testing Cochlear Implants, BAHA, Auditory Brainstem Implants, and Other Hearing-Assistive Devices Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment Septoplasty and Rhinoplasty Surgical Removal of Redundant Skin and Face/Neck Lift Procedures

August 2021 Effective Dec. 1, 2021 Reduction Mammoplasty Urine Drug/Alcohol Screening and Testing Microprocessor Controlled and Myoelectric Limb Prosthesis Pneumatic Compression Devices Wearable Cardiac Defibrillator

September 2021 Effective March 1, 2022 Non-Covered Services and Procedures (general section only, not genetics/DME)

Reimbursement highlights Check out our Reimbursement Policies on our website under Resources, Provider Resources, Support and Education. New Policy: Laboratory—Automated Labs Recently reviewed reimbursement policies: Itemized Bill Review for Inpatient Hospital Claims NCCI Reimbursement NCCI Knee NCCI Shoulder Reduced and Discontinued Procedures Surgical Assist., Co-Surgeons, Surgical Teams We also encourage providers to use the Claims Editing 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. For questions regarding the policies outside of medical coding, you may contact Provider.Reimbursement@wpsic.com.

Navigating the Claims Editing System In the interest of payer transparency, WPS Health Plan has included an interactive tool—the Claims Editing System (CES)—within our provider portal. This tool allows you to enter procedure codes, modifiers, diagnosis codes, dates of service, patient gender, date of birth, and place of service parameters. Through the CES, you can clearly see how code combination edits impact claims and have the opportunity to make adjustments prior to your submission. To access the CES, select the Claims Editing System link under Extras on the Quick Links panel. Upon entering the CES, you will see the following 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. Then 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 all applicable fields are entered, press the Submit button. Your results and rationale will be displayed, and you can export them by selecting Export to PDF. To start a new code combination, click the New Claim button.

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Utilization Management follows timeliness standards WPS Health Plan adheres to the following timeliness standards for review of requested services. The standards include: Non-urgent pre-service decisions are determined within 15 calendar days of receipt of the request Urgent pre-service decisions are determined within 72 hours of receipt of the request Urgent concurrent review decisions are determined within 24 hours of receipt of the request Post-service decisions are determined 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 provider that an extension is necessary. The date by which 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.

Affirmative statement on incentives Utilization Management (UM) decision-making is based only on appropriateness of care and service and existence of coverage. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.

Electronic Data Interchange—help us help you Need to contact the Electronic Data Interchange (EDI) team? For us to authenticate the call and effectively research your issue, please have this information before calling: Trading Partner ID Submission method—directly or through a clearinghouse NPI ISA Control Number (ISA 13) from file sent to WPS Health Plan The ISA 13 is NOT Protected Health Information (PHI) and serves to identify the file without using personal information. Claims count Date of submission Dollar amount If you are not a direct submitter, all the above information can be obtained by contacting your clearinghouse. If you have any questions or concerns, please contact us: EDI Help Desk Team                       800-782-2680 (option 1) EDI Marketing Team                       800-782-2680 (option 2) Email                                             edi@wpsic.com

Holiday closures reminder WPS Health Plan will be closed in observance of the following holidays: Independence Day Monday, July 5 Labor Day Monday, Sept. 6

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