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We are very pleased to announce that we have recently added a new Medical Director, Doctor Jason Kessler. Dr. Kessler is a practicing pediatrician, bringing over 25 years of primary care experience to our team. He has been instrumental in several new endeavors to automate and streamline WPS medical management processes, hopefully simplifying these operations for you and your staff, while expediting patient reviews.
Specifically, we have streamlined in-house authorizations for imaging services, physical therapy and chiropractic services. We have enhanced the electronic questionnaires for magnetic resonance imaging (MRI) and positron emission tomography (PET) requests through the iExchange portal, with the opportunity for faster approval of many of these exams. We may be expanding the iExchange portal to include additional services in the future, and encourage you to submit requests via iExchange.
As always, we are very grateful for your commitment to quality care and the excellent care and services which you provide to our members. If you have any questions or concerns, please contact me at Kevin.Rak@wpsic.com.
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Kevin M. Rak
Medical Director
WPS Health Insurance/WPS Health Plan
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WPS product offering refocuses on growth | |
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WPS Health Insurance is streamlining its product offering to simplify its business and make it easier for customers to select coverage. Due to changes in the health insurance market, our wholly owned subsidiary, WPS Health Plan (formerly Arise Health Plan), will no longer offer or renew HMO or POS individual or group health plans. As of June 30, 2024, we will transition exclusively to our WPS Health Insurance fully insured PPO individual and group health plans and WPS Powered By Auxiant self-funded group health plans.
In line with this transition, we are asking all health care providers to remove our old WPS Health Plan logo. Please remove our old logo from your premises, websites, materials, and any other relevant platforms by June 30, 2024, and replace it with our WPS Health Insurance logo or our WPS Powered By Auxiant logo, as appropriate.
Remove the following logos:
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Keep using or add these logos: | |
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We understand that adjusting your materials can require time and effort, and we sincerely appreciate your cooperation in this matter. Your prompt attention to removing our outdated logos by June 2024 will ensure a smooth transition and help maintain consistency across our network.
If you have any questions regarding this update, please do not hesitate to reach out to our provider relations team whose contact information can be found in our Provider Manual.
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Exploring Alternatives: Beyond GLP-1s for Diabetes and Weight Management | |
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With requests for GLP-1 receptor agonists such as Ozempic proliferating and attracting ample media attention, many patients are inquiring about GLP-1 receptor agonists for weight loss. While the GLP-1 receptor agonists may offer a dual benefit in reducing blood glucose and weight, they are costly and may not be appropriate for all patients. Additionally, the increased use of GLP-1 receptor agonists for weight loss has led to shortages that may be impacting your diabetic patients.
The American Diabetes Association (ADA) updated its “Standards of Care in Diabetes–2024” in December 2023. The updated recommendations indicate that blood sugar management and weight loss should be primary goals in patients with type 2 diabetes. They also indicate that additional cardiovascular and mortality benefits may increase with greater weight loss.1
ADA Recommendations:
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Individualized Treatment Plans: Recognize that each patient is unique. Tailor treatment based on their specific needs, preferences, and medical history.
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Lifestyle Modifications: Encourage patients to adopt healthier eating habits, engage in regular physical activity, and manage stress. These lifestyle changes can significantly impact weight and blood sugar control.
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Pharmaceutical Treatment: Evidence supports the use of metformin as first-line treatment in most patients due to its low cost and ability to promote modest weight loss and lower glucose. Patients with comorbid conditions such as heart or kidney disease may benefit from the addition of an SGLT-2 inhibitor, such as Jardiance or Invokana, or a GLP-1 receptor agonist.
The following GLP-1 receptor agonists may be covered with a documented diagnosis of type 2 diabetes or by meeting step therapy requirements (i.e., prior treatment with one or more select antidiabetic medications other than metformin within the last 130 days):
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| Bydureon | Mounjaro | Rybelsus | | Byetta | Ozempic | Trulicity | | |
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It’s important to note that WPS provides no benefits for health care services prescribed for appetite suppression, prediabetes, diabetes prevention, obesity, weight control, or weight reduction, regardless of whether such services are prescribed by a health care practitioner.
Therefore, the following GLP-1 receptor agonists, which are only indicated for chronic weight management, are excluded from coverage regardless of diagnosis:
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Overall, GLP-1 receptor agonists remain valuable tools, but they are not a one-size-fits-all solution. By combining evidence-based treatments, lifestyle modifications, and personalized care, you can empower your patients to achieve sustainable weight management and optimal diabetes control.
1“Standards of Care in Diabetes–2024”. Diabetes Care. Jan 2024: Vol. 47, issue Suppl 1. Retrieved from diabetesjournals.org/care/issue/47/Supplement_1.
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Site of Care Management for Specialty Medical Drugs | |
WPS partners with CareContinuum to provide utilization management services for specialty medical drugs. As of April 18, 2024, the CareContinuum Site of Care (SoC) Management program was implemented to assess and redirect administration of specialty drugs to more cost-effective sites of care when clinically appropriate.
The program includes clinical review of medical necessity as well as consideration of the site of service in which the drug is being administered. For many disease states and medication therapies, infusion therapy in a lower-intensity setting* is a safe and effective alternative to a higher-intensity setting. For many patients, receiving infusion therapy in lower-intensity settings may also be preferred over a higher-intensity setting such as a hospital or outpatient hospital setting.
*A lower-intensity setting is defined as:
- Home infusion provider
- Provider office
- Ambulatory infusion site
The SoC Management program reviews the requested drug and site of service and will apply certain exception criteria that allows either full approval of administration at a higher-intensity setting or, in some cases, a specified number of doses at the higher-intensity setting before redirecting the member to a lower intensity setting. The member’s clinical history and current condition are reviewed to determine if the member meets these criteria, which include but are not limited to:
- Clinical stability and need for immediate access to hospital services and/or enhanced monitoring
- Cognitive or physical impairments that may present an unnecessary health risk
- History of cardiac or pulmonary conditions that may increase the risk of severe adverse reactions
- Patient age
- History of severe or potentially life-threatening adverse event with the requested medication
- Patient ability to access alternative setting
SoC management is appropriate for many therapy classes, including the following:
- Enzyme Deficiency
- Amyloidosis
- Asthma/Allergy
- Blood Cell Deficiency
- Bone Modifiers
- Endocrine Disorders
- Immune Deficiency
- Oncology/Hematology
- Inflammatory Conditions
- Multiple Sclerosis
Thank you for the care you provide your patients and our customers. Your help in redirecting administration of specialty drugs to the most cost-effective sites of care is very much appreciated.
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For program-related questions, please contact: | |
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CareContinuum
Toll Free: 1-800-475-1954, Option 2
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Registering for the provider portal is easier than ever! | You asked and we listened. We are excited to announce that we have updated the provider portal registration process and access is now easier than ever. | |
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This latest update will ask providers to submit their Tax Identification Number (TIN), National Provider Identifier (NPI) and the details from only 1 remittance in the last 30 days or an invitation from an existing provider portal administrator.
Current registered providers can log in as before.
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2024 Provider Manual is available | |
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Stay informed on WPS policies and procedures including provider services, prior authorization, claims, and eligibility by reviewing our Provider Manual. The 2024 Provider Manual is available on our website.
Some updates include:
- Tiered Drug Benefits—Customer Responsibility Determination.
- Added additional information pertaining to using eviCore’s provider portal for medical oncology and radiation oncology prior authorizations.
- Added additional information to claims procedures for Durable Medical Equipment (DME)
To view the updated Provider Manual(s) go to wpshealth.com, click on Provider Resources > Support and Education > Provider Manual.
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Keep us informed of demographic updates | |
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We count on you, our preferred providers, to inform us promptly of the following, in order to maintain the accuracy of our provider directory and market your services effectively to our customers.
- Practitioners joining or leaving your organization
- Changes to practitioner name, licensure, or specialty
- Change in billing or other contact information
- Change in service location
- Acquisition of other medical practice or entity
- Change in Tax ID number or legal business name
- Change in ownership
You can notify WPS of provider demographic updates using one of the following methods:
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Practitioner Data Sheet: Allows you to add a new practitioner to your group, forward changes related to a practitioner’s demographic information or practice location or notify us of a practitioner’s termination from your group.
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Facility Data Sheet: This form allows you to add, terminate, or change information specific to facilities, including clinic physical location updates (opening, closing, relocating, etc.).
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Full File: If you are currently a health system provider that sends us a full file for updates, you may continue to do so. However, time-sensitive updates may be emailed to GBNetworkDevelopmentDept@wpsic.com.
As required by law, under the No Surprises Act, any material change in provider directory data must be reported to all payers in a timely manner. If the change results in out-of-network benefits, the responsibility falls to the provider. Your help in providing demographic updates is very much appreciated by us, our customers, and referring physicians.
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Important Notice regarding using Practitioner and Facility Data Sheets:
Make sure you are using the most up-to-date version of our forms located on our website. Use of an outdated form may cause delays in the credentialing, contracting and/or claims payment processes.
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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 Insurance/Health Plan Medical 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.
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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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CONFIDENTIALITY NOTICE: This e-mail, including any attachments, may contain confidential, privileged and/or proprietary information which is solely for the use of the intended recipient(s). Any review, use, disclosure, or retention by others is strictly prohibited. If you are not an intended recipient, please contact the sender and delete this e-mail, any attachments, and all copies. | |
WPS Health Insurance | 1717 W. Broadway | Madison, WI | wpshealth.com | | |
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©2024 Wisconsin Physicians Service Insurance Corporation and WPS Health Plan,, Inc.
All rights reserved. JO25580
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