Provider Resources Forms and Documents

• Family Care/CLTS Corrected Claim Form Tip Sheet
• Family Care/CLTS Corrected Claim Form
• Corrected Claim Form

• Coding corrections (i.e. corrected diagnosis, corrected billing code, addition/correction of modifier).
• Disputes of bundling denials require submission of medical records.
• Corrected claims replace an original claim submission that had incorrect information. For example, you may submit a corrected claim if you need to correct the date of service or add a modifier. All lines from the original claim should be included even if they were correct in the first submission.
• A corrected claim must be submitted within 180 days of the date the original claim processed.

• Claims Reconsideration Form

• Use for timely filing denials, bundling disputes, provider reimbursement, and medical documentation required denials
• You should submit a claims reconsideration request when you believe a claim was paid incorrectly.
• Appropriate claim reconsideration requests include, but are not limited to:
• Amount is different than what provider expected
• Claim was filed in a timely manner, when provider has proof
• Difference in Coordination of Benefits (COB) information
• A claim reconsideration request is not an appeal and does not alter or toll the deadline for submitting an appeal on any given claim.
• A claim reconsideration request must be submitted within 180 days of the date the claim processed.

The following documents apply to your rights under HIPAA regarding your protected health information (PHI).

• More Information on HIPAA
• Notice of Privacy Practices
• Authorized Representative Form for Grievance/Appeal
• Authorization for WPS to Disclose Health Information
• Confidential Communications
• Consent to Unsecure Email Communication
• Request to Access PHI
• Request to Amend PHI
• Instructions for Completing the Customer Authorization Form
• Privacy Complaint Form

• Neuropsychological Testing Request Form

• Kidney Dialysis Prior Authorization Request Form
• Prior Authorization and Referral Request Form
• WPS Medical Prior Authorization List
  For Aetna Signature Administrators Participating doctors and hospitals please contact American Health Holdings at 866-726-6584 for prior authorization.
• Medical oncology and radiation oncology requests for authorization(s) will be reviewed by eviCore Healthcare. To request an authorization(s):
  Log onto https://www.evicore.com/provider (preferred)
  Phone: 800-475-1954
  Fax: 800-540-2406

• Provider Appeal Form

• Use for post-service claim denials due to non-compliance with prior authorization requirements or services that are determined to be not medically necessary or experimental, investigational, or unproven.
• You should submit a provider appeal if you wish to challenge a decision or request an exception.
• You have up to 60 days from the date of denial to submit an appeal request.

Appropriate provider appeals include:

• Claim denied for lack of prior authorization but prior authorization was obtained.
• Claim denied for lack of prior authorization but provider believes prior authorization should not be required due to extenuating circumstances.
• Services denied as not medically necessary or experimental, investigational, unproven, when provider submits clinical documentation to show that the service should not be denied as such.

• Practitioner Data Sheet
• Facility Data Sheet
• W9 Form
  
  Submit W9 Form

General

WPS' drug prior authorization program supports evidence-based treatment and is intended to optimize the care provided by practitioners to our customers. Drugs subject to prior authorization may have specific safety issues, may require a higher level of care coordination, may compete with other products that offer similar or greater value, or may require specific testing to identify appropriate patients. The prior authorization process gathers information so that a coverage decision can be rendered.

Requests for specialty and non-specialty drugs are either reviewed by our Pharmacy Benefit Manager, Express Scripts, or in rare instances, WPS. Requests for medical oncology (chemotherapy) are reviewed by our partner, eviCore.

• WPS Drug Prior Authorization List
• For pharmacy drugs, log on through your preferred ePA Portal (preferred)
  To learn how to get started, visit bit.ly/express-scripts-easy-epa or use the ePA feature through your electronic health record service, if available
  Phone: 800-475-1954
  Fax: 833-933-2367
• For medical specialty drugs, log onto https://www.evicore.com/provider
  Phone: 800-475-1954
  Fax: 833-933-2367

Additional Information Concerning Specialty Drugs

As noted above, WPS has engaged Express Scripts to assist with specialty drug management. Express Scripts will review each treatment plan relative to evidence-based guidelines that may include step-therapy protocols. Express Scripts will ensure the specialty drug is provided in the most appropriate, cost-effective setting. This includes self-administration or the home setting depending on the situation. Specialty drugs dispensed without proper authorization will not be reimbursed, and the customer can be balance billed.

A provider can initiate a specialty drug authorization by calling Express Scripts at 800-475-1954.

• Refund Form

Under Sec. 111 in the H.R. 133, the Consolidated Appropriation Act, health plans are required to send patients an Advance Explanation of Benefits (AEOB) after receiving a good faith estimate notification from a provider or facility that an individual is scheduled to receive an item or service. In addition, 2009 Wisconsin Act 146 requires hospitals, insurance plans, and health care providers to disclose information about the cost and quality of health care services. Complete the request form to obtain an estimate of out-of-pocket expenses for the member.

• Estimate for Out-of-Pocket Costs