Winter 2023

Doctor's note

The new year has become the symbol of new beginnings and a time to make changes for the better. Effective Jan. 1, 2024, WPS will begin to internally review prior authorization requests for high-tech imaging services rather than utilizing the services of an external vendor. This will apply to MRI/MRA/MRS, CTA, and PET scans. As of the first of the month, requests for these prior authorizations, including clinical documentation, will need to be submitted via the WPS web-based tool, iExchange, or faxed to 608-226-4777. 

In addition, we will be assuming the duties of internally reviewing requests for physical therapy, occupational therapy, speech therapy, as well as for spinal manipulation/chiropractic treatments.  

By removing the prior authorization requirement for most CT services and also for the majority of therapeutic services, we hope to make the experience much more provider-friendly and customer-friendly, while also ensuring the highest quality of health care. Please see the article in this edition for more detailed information. 

All of us at WPS have a deep appreciation for the work you do, and we all thank you very much for the excellent service you provide to our customers. I look forward to continuing to work together throughout upcoming new year. 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

Benefit and Prior Authorization changes for 2024

Effective Jan. 1, 2024, WPS is making the following changes:

Prior Authorization of High-Tech Imaging Services

• WPS will end the use of National Imaging Associates (NIA), subsidiary of Evolent Health LLC, for review of CT scans, MRI/MRA/MRS, nuclear cardiology, and PET scans. All prior authorization requests will need to be sent to WPS for review and approval.
• Except for CT angiographic exams, CT services will not require prior authorization and will be removed from the prior authorization listing. In addition, Nuclear Cardiology Testing will not require prior authorization and will be removed from the prior authorization list.
• In conjunction with this change, WPS has developed High-Tech Imaging Medical Policies that will be used to determine if a High-Tech Imaging service is eligible for coverage by the plan. High-Tech Imagining Medical Policies will be available on our website under Medical Policies | WPS Prior Authorization Form, by Dec. 31, 2023.
• You may submit a prior authorization request, including clinical documentation, by using the WPS web-based tool, iExchange, or via fax, 608-226-4777. When submitting prior authorizations via fax, please use the WPS Prior Authorization Form, which can be found on our website under Providers > Forms and Documents > Prior Authorization Information. 

Benefit Limitations

Some specific services will have benefit limitations. These limitations do not apply to all Plan types, and providers are strongly encouraged to verify a customer's benefits prior to providing services. Regardless of benefit limits, all services must be medically necessary to be eligible for coverage.

Physical, Occupational, and Speech Therapy

• Fully Insured Large Group and ASO will move to a limited combined benefit of 25 outpatient visits per calendar year. Once exhausted, no further PT/OT/ST services will be eligible for coverage, regardless of medical necessity.

• Fully Insured Small Group and Individual plans will not have a PT/OT/ST benefit limit. However, all PT/OT/ST services must be medically necessary to be eligible for coverage. To ensure services are medically necessary, medical records may be requested and reviewed to determine if they are eligible for coverage.

Spinal Manipulations

• A limit of 18 Spinal Manipulations will become the standard for ASO members, with no coverage of Spinal Manipulation beyond the 18 services, regardless of medical necessity.

• Fully Insured members, including Small Group, Large Group and Individual will not have Spinal Manipulation limits. However, all Spinal Manipulation services must be medically necessary to be eligible for coverage. To ensure services are medically necessary, medical records may be requested and reviewed to determine if they are eligible for coverage. 

Optum - Utilization Management

• Optum will no longer manage any WPS members admitted to the Neonatal Intensive Care Unit (NICU). Facilities are required to submit notification to the WPS clinical team, via faxing 608-226-4777 or by calling 800-333-5003, when a member is admitted to the NICU for the support and management of ongoing NICU services.
• Optum will no longer provide services to WPS members with end stage kidney disease. For members requiring dialysis, providers are required to submit notification to the WPS clinical team, via faxing 608-226-4777 or by calling 800-333-5003, for support and management of ongoing dialysis services.

Should you have any questions or need additional information, please contact our Customer Service Team at 800-765-4977 Monday through Friday 8:30 a.m. – 5:00 p.m. CT.

Prescription Drug Program updates go into

effect Jan. 1

You can find information about our Prescription Drug Program on our website, including:

• Our Prescription 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;
• The Drug Prior Authorization List, which identifies the applicable medications, as well as who to contact to initiate the process; AND
• Formularies/Preferred Drug List, which contain the lists of drugs that are covered under the pharmacy benefit, including generic drugs, preferred brand-name drugs, specialty drugs, and biosimilars.

If you would like a copy of this information, please contact our Provider Contact Center at 800-765-4977.

Formulary, Preferred Drug List changes for 2024

The updates to the Formulary/Preferred Drug List for 2024 are available now.

National Drug Code requirement

WPS requires the National Drug Code (NDC) on all specialty drugs, unclassified drugs, and any outpatient claims with a revenue code range of 0631 through 0637. If the required NDC is not present, the claim and/or claim line will be automatically denied.  

The Claim Procedures section in the WPS Provider Manual references this requirement:  

Coding Requirements 

• Healthcare Common Procedure Coding System (HCPCS) for Ancillary Services/Procedures
• Code on Dental Procedures and Nomenclature (CDT)
• Current Procedural Terminology (CPT) for Physicians' Procedures
• International Classification of Diseases (ICD)

• National Drug Codes (NDC)
• Codes maintained by the National Uniform Billing Committee (NUBC) for institutional use
• National Provider Identifier (NPI)
• Taxonomy 
• Other specific coding requirements as determined by the standard format 

All billed codes must be appropriate and active for the specific date of service billed.  

Evernorth Real-Time Prescription Benefit 

Patient-specific cost and coverage at the point of care

WPS partners with eviCore healthcare and CareContinuum^TM under the Evernorth^SM umbrella for our benefit management solutions.

Evernorth’s Real-Time Prescription Benefit (RTPB) provides physicians with patient-specific cost and coverage information directly at the point of care. With RTPB, you have access to your patient's out-of-pocket costs, coverage alerts, therapeutic options, and pharmacy choices directly within your electronic medical records (EMRs) workflow.

Personalized benefit insight at the point of care enables you to make an informed decision about options that are right for your patients that could save them money. For you, RTPB removes the guesswork, saves time, and enables you to get back to what matters most—caring for your patients. However, many physicians are still unaware of RTPB and the value it brings in optimizing their time spent with patients.

To learn more about how Real-Time Prescription Benefit optimizes your workflow and patient care, please visit evernorth.com/resources/rtpb.

Why RTPB matters:

• Fewer unpleasant surprises. 75% of patients have been surprised by costs at the pharmacy.¹
• Time saved. 86% of doctors feel like they don’t have enough time with their patients.²
• Member savings. $250M in member savings were driven by RTPB in 2021.³

Change to publication schedule

We publish WPS Provider Network News to inform you of current and upcoming news, including claims policy and procedure updates, departmental updates, upcoming office closure dates, and more. 

In 2024, we will be changing the publication schedule from four times to three times per year. Issues will be published in the following months:

• April 
• August 
• December

You can still access current and archived newsletters on the WPS website. 

Submitting practitioner additions and terminations for your organization

The WPS Provider Directory is more than a reference guide for our customers. It also helps us market your services appropriately and ensures our customers have uninterrupted access to health care services. If you have any additions or terminations within your organization, please use the Practitioner Data Sheet form to notify us.

When submitting an addition or termination for your organization, please begin by completing the following three sections of the form:

1. Contact information
2. Credentialing contact
3. Practitioner information

Adding a Practitioner

To add a practitioner, check the box Add Practitioner. Then, fill in all the fields under Section A—Add Practitioner. Please note, there is additional information needed on the next page, such as primary practice information, hospital affiliations, and billing information. 

Terming a Practitioner

To terminate a practitioner from your organization, check the box Term Practitioner. Then enter the termination date and reason under Section B—Term Practitioner. 

You can also use the Facility Data Sheet to provide Facility updates as they occur by completing the appropriate fields in sections C and/or D.

Once you complete the Practitioner Datasheet(s) or Facility Datasheet(s),

send the forms to GBNetworkDevelopmentDept@wpsic.com or

fax to 920-490-6923 Attn: Network Development

IMPORTANT TIP: Ensure you are using the most current form on the website to avoid delays in credentialing, contracting, and/or claims payment process.

2024 Provider Manual coming soon to our website

The provider manual has several updates including:

• Tiered drug benefits

• Durable medical equipment claims

• Prior authorizations for high-tech imaging

Medical Policy updates and review

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

View the revisions to the medical polices.

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 call 800-333-5003, ext. 06984.

Policies that will be reviewed in the upcoming months include:

January 2024 (effective July 1, 2024)

• Bariatric Surgery
• Biofeedback Treatments and Devices
• Blepharoplasty, Blepharoptosis Repair, Brow Lift, and Related Procedures
• Corneal Treatments and Specialized Contact Lenses
• Multiplex Pathogen Testing for Infectious Disease
• Non-Covered Services and Procedures—DME

February 2024 (effective July 1, 2024)

• Ankle Arthroplasty, Total 
• Artificial Disc Replacement
• Bone Growth Stimulators
• Meniscal Allograft Transplantation
• Neuropsychological Testing
• Shoulder Replacement
• Non-Covered Services and Procedures—Genetics

March 2024 (effective July 1, 2024)

• 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
• Skin and Soft Tissue Substitutes
• Non-Covered Services and Procedures—General Section

April 2024 (No meeting)

May 2024 (effective Nov. 1, 2024)

• Back Pain—Sacroiliac and Coccydynia Treatments
• Back and Nerve Pain Procedures—Radiofrequency Ablation, Facet, and Other Injections
• Back and Neck Pain Procedures—Epidural Injection
• Deep Brain Stimulation
• MRI Neck, Face, Orbit (NEW)
• Non-Covered Services and Procedures—DME

June 2024 (effective March 1, 2024)

• Capsule Endoscopy
• Cell-Free DNA Testing
• Cochlear Implants, BAHA, Auditory Brainstem Implants, and Other Hearing Assistive Devices
• Glaucoma Surgical Treatments
• Infertility and Recurrent Pregnancy Loss Testing and Treatment
• Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti
• Tumor Treating Fields (Alternative Electric Field Therapy)
• Pulmonary Artery Pressure Monitoring (CardioMEMS)
• 3D Rendering of CT/MRI/US
• Spinal Manipulation Treatments and Chiropractic Services (NEW)
• Non-Covered Services and Procedures—Genetics

You don't have to call for patient eligibility and claims status

Do you currently verify patient eligibility or claim status by a phone call? Did you know you could do this online by using electronic transactions—AND save time and money by doing so? Talk to your vendor about your system’s capabilities. They may provide hardware, software, and/or ongoing support for a total office automation or submission of EDI transactions.

With EDI, you can:  

• Lower administrative, postage, and handling costs
• Maintain investment in your billing system
• Avoid payment delays or interruptions
• Waste less time on the phone checking eligibility
• Lower operating costs to verify eligibility
• Receive payments more quickly
• Endure fewer reviews

WPS can be your single point of contact for EDI support that’s accurate, timely, and available through a variety of channels. The EDI Help Desk provides front-line support regarding basic EDI information and troubleshooting.

You can reach the EDI Help Desk at 800-782-2680, Monday-Friday, 8 a.m.-4:30 p.m. CT.

2024 holiday schedule

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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¹Evernorth physician sentiment survey conducted in 2020. ²Evernorth physician sentiment survey conducted in 2020.

³Cumulative member savings across the 2021 Book of Business. Evernorth Knowledge Solutions RTPB 2021 savings analysis.

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