In This Issue
New Staff
HIRSP Update
Credentialing Corner
Policy Changes
ID Card Updates
Paperless Initiative

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The Doctor's Note
January 2014

Dear Colleagues:


Happy New Year! We hope you and your family had a healthy holiday season and stayed warm in this Wisconsin weather!


Here at WPS, we are excited for the beginning of the new year. With the changes in health care and health insurance plans, this year will be a learning process for everyone in the industry. We promise to work with you every step of the way to ensure our members get the best possible care.


This newsletter has some important updates about the HIRSP extension and credentialing reminders. Also, we'd like to remind you of the WPS paperless initiative that was launched on Jan. 1, 2014.


Read on and we hope you enjoy this edition of our WPS Provider Connection!


Best Regards,

Viren Bavishi, D.O.  

New Staff Announcement

 We are excited to announce the addition of our new Chief Medical Officer and Medical Director!


Dr. Phil Colmenares has joined WPS as the new chief medical officer. He has extensive experience as a practicing physician and an administrator in clinic and health plan settings, most recently as senior medical director at Security Health Plan.


Dr. Catherine Inman has joined WPS as the new medical director. She was previously the medical director at Physician's Plus, and an associate medical director for the Gundersen Lutheran Health Plan in La Crosse, WI. She has experience in research and administration from working at the National Institute for Occupational Safety and Health.


The work done in Medical Affairs and WPS' overall approach to integrated care management and risk management is one vital piece of what the Health Insurance Division needs to do very well to ensure growth, profitability, and overall success. In his new role, Dr. Colmenares, will lead the quality and accreditation efforts, provide valuable insight and help to set the strategic direction in areas such as expanded provider partnerships, provider reimbursement models, and risk management among other duties, with assistance from Dr. Viren Bavishi and Dr. Inman.


Additionally, he will work to advance WPS' role and leadership position in important organizations such as the Wisconsin Medical Society, Wisconsin Collaborative for Healthcare Quality, and Wisconsin Health Information Organization.


Dr. Colmenares will lead Medical Affairs with support from Viren Bavishi, DO, medical director, Dr. Inman, medical director, Mary Umbeck, senior director of Medical Affairs; Mike Chester, RPh, director of Pharmacy.

HIRSP Update

Important Information for HIRSP Providers 

With the extension of HIRSP policies through March 31, 2014, HIRSP members have more time to make decisions about their health care coverage. HIRSP benefits and deductibles will not change in 2014, but the deductible for HIRSP members who extended their coverage was reset on January 1, 2014. In addition, since HIRSP members have a 31-day grace period to pay their premiums, we may not know when they secure alternative coverage. Therefore, when checking member eligibility and benefits, please keep in mind the following:


  • HIRSP member ID cards used in 2013 will continue to be used in 2014. Please verify with members that HIRSP coverage is in place, and that they are aware of their deductible resetting in January.
  • Member benefits for HIRSP policies remain unchanged. You can review them at Here's a short list of services that require prior approval:
    • Surgery for obesity
    • Transplant services
    • Any durable medical equipment that will be rented for more than three months or with a purchase price greater than $1,500;
    • Any prosthetic with a purchase price greater than $1,500;
    • Selected pain management procedures, stimulators and pumps
    • Non-emergency scans, MRIs, surgeries and hospitalization
    • Intravenous (IV) therapy/infusion therapy performed in the patient's home
    • Specialty drugs
    • Experimental medical technology or methods.

Please fax your prior approval or precertification request to 608-226-4711.

  • You can view your Provider Remittance Advices (PRAs) online using Emdeon Payment Manager or Emdeon Vision for Claim Management. Simply select WPS Health Insurance (ID SX022) from the Payer list and access the exact PRA images you receive in the mail - now all in one place and available 24 hours a day!    

Thank you for your partnership in helping ease this transition for HIRSP policyholders.

Credentialing Corner

Credentialing Reminder


Do you have new practitioners joining your practice? Remember to have them credentialed!


WPS requires credentialing review and approval of all practitioners who have an independent relationship with our PPO network. Credentialing approval is required before new practitioners begin seeing WPS members. Your practitioners may experience a delay in network participation if credentialing approval is not obtained prior to their start date.


You may notify WPS of new providers by completing and submitting the WPS Practitioner Data Sheet found on our  website. Please submit the form well in advance of the practitioner's start date to allow time for gathering and verification of professional qualifications.


WPS has partnered with the Council for Affordable Quality Healthcare (CAQH) for credentialing. Please ensure your practitioners regularly update their information on the CAQH website. Don't have a CAQH application started? Don't worry! Additional information regarding the CAQH application process will be provided once we receive your Practitioner Data Sheet.


For additional information regarding the WPS credentialing process, please refer to the  WPS Provider Manual or contact our credentialing team at

Med Policy Changes
The following medical and pharmacy policies were approved at the 12/13/2013 WPS Medical Policy Committee meeting. See the highlights below. Policies will be posted on the WPS Provider website by January 20, 2014.


To view the updated policies, go to:   


WPS welcomes your feedback regarding research and development of criteria in the Medical Policies. Comments regarding specific criteria should include supporting references from peer-reviewed high level scientific literature. Please respond to


Pharmacy Policies





Gonadotropin Releasing Hormones

Hormone Supplements for non-contraceptive useHuman Granulocyte-Colony Stimulating Factor


Inflammatory Disease Medications

Morbid Obesity

NEW! Multiple Sclerosis Medications

Omontys-No Longer Covered
as it has been removed from the marketOncology conditions, Medical Treatment of...


Rituxin-Additional indications


Medical Policies


Negative Pressure Wound Therapy

Occipital Nerve Block

Oral Appliances for OSA retired. Contents were incorporated into Sleep Treatment policy

Osteogenic stimulator (Bone Growth Stimulator)

Reduction Mammoplasty

Sacroiliac Joint Treatments (SI Injections, Ablation, Fusion)- added non-coverage of SI ablation and SI fusion for back pain

Salivary Hormones

Sleep Disorder Testing

NEW! Sleep Disorder Treatment (Oral appliance and PAP devices)

Spinal Cord Stimulators

Transmyocardial Revascularization (TMR).

Video EEG

Vision Therapy

ID Card Updates
Changes to Member Identification Cards in 2014

A new year is here and many changes related to the Patient Protection and Affordable Care Act (PPACA) are taking place in the health care industry. That means many WPS members will receive new health insurance identification (ID) cards this year. Some members will receive new ID cards at the start of the new year and others will receive new ID cards in upcoming months upon renewal of their plan.  

All WPS member ID cards include the member name, member ID number, copayment information, WPS contact information, and claims submission address. However, as of January 1, 2014, you will see a Metal Tier listed on the ID cards of members enrolled in an individual plan or a small employer group plan that includes that include Essential Health Benefits.  WPS Metal Tiers are defined as Bronze, Silver, Gold, Platinum, and Catastrophic. Members enrolled in plans through a large employer group will not have a Metal Tier listed on their id card, but their benefits may differ from previous years.  

WPS Members are asked to carry their ID card with them at all times and to present it when they receive services. We encourage you to have your patient present their current ID card each time they visit. Member information is listed on the front of the card, while important contact information is listed on the back.  If you have any questions related to a member's benefits, please check benefits through our Provider portal at or call WPS Customer Service at 800-765-4977.
Paperless Initiative

NEW: Check out your 2013 Provider Remittance Advices online!


Now you can view your Provider Remittance Advices (PRAs) online using Emdeon Payment Manager or Emdeon Vision for Claim Management. You can view all PRAs issued in 2013 and see the detailed explanation codes and remarks. Plus, if you have registered multiple facilities and Tax IDs to be included in your main Emdeon account, you can see all associated PRAs in one place.


Simply select WPS Health Insurance (ID SX022) from the Payer list and access the exact PRA images you receive in the mail - now "electronic" and available 24 hours a day!    


Need to register?  


to register for Emdeon Vision - it's FREE!  


Or call 877-EMDEON-6 (877-363-3666) to get set up!  


Already registered?  

Login here: and view your PRAs today!


We hope that you enjoy this new, easy, and electronic access to your PRAs!

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