Health Plan Price Transparency
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. As of July 1, 2022, most group health plans and issuers of group or individual health insurance are posting pricing information for covered items and services. Learn more at CMS.gov.
WPS complies with CMS requirements and posts Machine Readable Files (MRFs) that display the cost for in-network rates and allowed amount rates for providers. WPS Machine Readable Files can be accessed here.
Additionally, WPS has a cost estimator tool available to members through their customer account, or by calling Customer Service, to obtain personalized cost estimates. WPS also offers a consumer cost estimate comparison tool — log in to your customer account to access it. Functionality including the ability to populate an “estimate only” member-specific benefit and out-of-pocket cost information is now available.
Please note: Customized estimates are available based on your specific benefit plan and cost sharing by logging in to your customer portal through WPS, or by contacting the WPS Customer Service number on your ID card. If you do not have your ID card available, click here.
No Surprises Act
Out-of-Network Liability and Balance Billing FAQs
As a general rule, PPO plans make use of provider networks. An in-network provider is one who has contracted with WPS to provide services to our customers for specific pre-negotiated rates. An out-of-network provider is one who has not contracted with WPS. Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider. While there are some exceptions, in many cases, WPS will either pay less or not pay anything for services you receive from out-of-network providers.
At the written request of our customers, WPS will provide a good faith estimate of the reimbursement WPS will expect to pay and the customer’s responsibility (out-of-pocket costs) for the specified health care service being considered. This process does not take the place of a prior authorization, prior approval, or pre-certification.
Please be aware that any requested pre-service estimate is a verification of benefits and not a guarantee of payment. Payment is based on the terms, conditions, and provisions of the policy/plan and is subject to the provider’s contracted rates in effect at the time the service is performed including, but not limited to:
- Requirements for medical necessity
- Prior authorization/Pre-certification
- Exclusions for work-related injury
- Provider network affiliation
- Pricing adjustments due to negotiated transplant coverage
- Medical claim coding guideline
Maximum allowable fee levels will apply to out-of-network providers and services rendered. This means enrollees are responsible for any charge that exceeds the maximum allowable fee level for authorized services received from out-of-network providers. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
Also, the estimate of out-of-pocket expenses that will be prepared is based on information submitted to WPS, along with claims and benefits we have processed at the time of our inquiry response. WPS will assume no modifications or complications occur in the treatment plan.
On Jan. 1, 2022, the Federal No Surprises Act (NSA) went into effect, protecting consumers from surprise bills for emergency services provided at an in-network facility. As part of the NSA, when a WPS customer seeks care from a provider for a service identified as being part of the Federal NSA program, a Qualifying Payment Amount (QPA) is applied to the health care claim. The customer is responsible only for the cost-sharing portion associated with that QPA. The medical provider is not permitted to bill the customer for any portion of the amount charged beyond the cost-sharing or other amounts not covered under the health plan.
