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• Summer 2026 WPS Provider Network News
• Winter 2026 WPS Provider Network News
• Fall 2025 WPS Provider Network News
• Summer 2025 WPS Provider Network News

• Spring 2025 WPS Provider Network News
• Winter 2024 WPS Provider Network News
• Fall 2024 WPS Provider Network News
• Spring 2024 WPS Provider Network News
• Winter 2023 WPS Provider Network News
• Fall 2023 WPS Provider Network News
• Summer 2023 WPS Health Insurance Provider Connection
• Spring 2023 WPS Health Insurance Provider Connection

Log in to EDI for a secure data transfer of information.

Log in to iExchange to quickly submit prior authorizations.

See medical prior authorization list

• For Aetna Signature Administrators Participating doctors and hospitals, please contact American Health Holdings at 866-726-6584 for prior authorization.

See drug prior authorization list

• 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

Please read before continuing:

Affirmative statement regarding incentives

Integrated Care Management decision-making at WPS Health Insurance is based solely on appropriateness of care and existence of coverage. WPS Health Insurance does not reward practitioners or other individuals for issuing denials of coverage. Financial incentives for Integrated Care Management decision-makers do not encourage decisions that result in underutilization.

Disclaimer:

To find Medical Policy guidelines for a patient covered by Medicare, go to the Government Services website.

Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in these policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs Medical Policies in all their coverage determinations. Contact Customer Service as listed on the customer card for specific plan, benefit and network status information.

Medical Policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health, to assist in administering health benefits. These medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

For specific patient-related policy or medical coding inquiries, please contact WPS Health Services at 800-333-5003 with the applicable patient name and customer number, along with the procedure, service or treatment in question.

We welcome your feedback regarding medical policies or MCG Health guidelines.

For questions or comments regarding research and evidence development of a specific criteria, general medical policy or MCG Health questions, contact the Medical Policy Committee at medical.policies@wpsic.com. To request an assessment of new technology or medical policy criteria by the Medical Policy Committee, please complete the New Technology and Medical Policy Assessment Request Form, attach supporting documentation from peer-reviewed high-level scientific literature and email to the committee at medical.policies@wpsic.com.

For questions regarding medical coding related to policies, contact the Code Governance Committee at codegovernance@wpsic.com.

NOTE: The email addresses above should NOT be used to send personal health records or customer identified information.

This disclaimer applies to all past and present medical and pharmacy policies.

I understand and accept the above information

• April 2026
• REVISED September 2025
• November 2024
• August 2024
• April 2024
• February 2024 - High-Tech Radiology Medical Policy Updates
• December 2023
• September 2023
• June 2023
• March 2023
• December 2022

To help you bill confidently and get paid accurately, we’ve put together our reimbursement policies. These guidelines outline coverage, billing requirements and payment details so you have clear, reliable information when submitting claims.

• Anesthesia Reimbursement Policy
• Automated Labs Policy
• Bilateral Procedures
• Consultations Reimbursement Policy
• Diagnosis Code Accuracy
• ER Facility Level of Service Review Policy
• Increased Procedural Services Policy
• Itemized Bill Review for Hospital Claims
• Mid-level Provider Reimbursement Policy
• Multiple Procedure Reduction Policy
• NCCI Reimbursement Policy
• Preventive and E&M Reimbursement Policy
• Reduced and Discontinued Procedures
• Separate Procedure Policy
• Split Surgical Procedure Policy
• Status B Policy
• Surgical Assist. Co Surgeon, Surgical Teams
• Venipuncture Policy
• Virtual Care Policy

Preferred drug lists for our health plans:

• Large Group Health Plan formulary
• Non-Transitional Individual Health Plan formulary
• Small Group and Transitional Individual Health Plans formulary
• Short-Term Health Plans formulary
• The for prescription medications that require prior authorization, view our list. If a medication you are prescribing is on this list, you will need to get an approved prior authorization from us. The contact information for a prior authorization can be found on our prior authorization list.

• Claims reconsideration form
• Corrected claim form
• Corrected claim form for EPIC Medicare Supplement Plans

Use this form to notify WPS of any additions, changes or terminations to facilities within your organization.

• Authorized representative form for grievance or appeal
• Customer authorization form
• Instructions for completing customer authorization form
• Confidential communications
• Consent to unsecure email communications
• Request to access PHI
• Request to amend PHI
• Privacy complaint form

Use this form to notify WPS of practitioner additions, changes or terminations within your organization.

• Prior authorization and referral request form
• Kidney dialysis prior authorization request form

• Use this form 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.

Prior authorization is the process of receiving written approval from WPS for services or products prior to being rendered. The provider requests and submits the prior authorization. Services are still subject to all plan provisions including, but not limited to, medical necessity and plan exclusions.

We encourage customers to verify prior authorization is requested by their provider and approved by WPS.

The 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

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 billed for the balance.

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

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

Go to my.wpshealth.com/en/provider and click on Register.

• Must contain a minimum of 9 characters and maximum of 20 characters
• Must contain at least 1 upper case character
• Must contain at least 1 lower case character
• Must contain at least 1 number
• Must contain at least 1 special character ($, #, _, -, %)
• Cannot contain spaces
• Cannot be the same as the previous 4 passwords

Administrators: If this is your first visit to our new, secure provider portal, you will need to create a new account. If you’re a provider with an existing account, please log in using your established credentials. If you have forgotten your user ID or password, please use the link provided on the login page. If you do not have an account, please use the link below to register or see your administrator for details.

• Adding additional users is easy. Once the administrator account is established, the person may create new accounts for other clinic staff as needed.

Log in to your provider portal, click on the Patient Eligibility link. Use the Patient Eligibility Search option to search for a customer using the customer number and date of birth OR the customer first name and/or last name and date of birth.

Please refer to the patient’s WPS ID card for the correct product name and logo.

WPS—A health solutions company
P.O. Box 21341
Eagan, MN 55121
FAX: 608-327-6332 (do not include cover sheet)

Please refer to our Receiver and Payer ID codes reference document.

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.

You should submit a claims reconsideration request when you believe a claim was paid incorrectly.

• Use for timely filing denials, bundling disputes, provider reimbursement and medical documentation required denials.
• 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.

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.

Please fill out our facility data sheet to notify WPS of any additions, changes or terminations to facilities within your organization.

Please fill out our practitioner data sheet to notify WPS of practitioner terminations, changes or additions within your organization.