Transparency in Coverage

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Transparency in Coverage

What is the difference between an in-network provider and an out-of-network provider?

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. As a general rule, PPO plans make use of provider networks. Some exceptions to out-of-network liability would be lab work, radiology, or pathology sent from your in-network doctor or facility to an outsourced facility that is out of network. Since the customer does not have control over where labs or pathology are being sent, we would allow at the in-network benefit level.

What kind of financial liability does an enrollee have for out-of-network services?

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 in an emergency room at a hospital or in an independent feestanding emergency department, air ambulance, and professional services when that professional service was performed 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.

For more information see Your Rights and Protections Against Surprise Medical Bills Notice

How can an enrollee submit a claim if the provider failed to submit the claim? What is the process?

After health care services are provided to you, a claim must be correctly submitted to us. The claim can be submitted by you or the health care provider. In-network providers will handle the coding and submission of claims on your behalf.

For out-of-network providers who do not code and/or submit claims, the following information must be filed with us within the time frame specified in your certificate of coverage.

  • Claim forms (see requirements for claims listed below)
  • Any relevant documents received from the health care provider at the time of the health care service
  • Proof of payment

Covered persons who receive health care services in a country other than the United States will need to pay for expenses up front and then submit the claim to us for reimbursement. We will reimburse you for any covered amount in U.S. currency. The reimbursed amount will be based on the U.S. equivalency rate that is in effect on the date you paid the claim or on the date of service if paid date is not known.

Enrollee claim submission time frames are specific to the certificate of coverage. A typical time frame is 90 days from service date, but can vary based on the specific certificate provided. Enrollees can submit any type of form as a claim as long as it meets the criteria below:

Claims should be itemized and include:

  • Provider of the service
  • Diagnosis
  • Date(s) of service
  • Services provided
  • Amount charged for the services
  • Enough information to identify the enrollee (for example, customer number, copy of customer ID card, etc.)

Please also submit a receipt if you have already paid for the service. No form is required.

For questions or for where to submit claims, please see the Customer Service section of our Contact page.

What is a grace period?

Enrollees who are enrolled in coverage but fail to make premium payment by the assigned due date have a grace period before their coverage can be terminated. The grace period is different for individuals who receive an advance premium tax credit (APTC) and those who do not. Individuals receiving an APTC have a grace period of three months. Those who do not receive an APTC have a grace period that is set by state law or regulations.

What does claim pending mean?

Claim pending means the issuer has not yet paid the medical claim.

How are claims paid during the grace period and following months?

Issuers are required to pay for medical care received during the first month of the grace period for enrollees who are receiving an APTC. However, for the second and third months of the grace period, issuers may withhold or “pend” payment for medical claims until the enrollee pays all outstanding premiums. If payments are not made in full and the plan is terminated, the individual will be responsible for paying any medical expenses incurred during the second and third months of the grace period.

Can a claim be denied retroactively, even after the enrollee has obtained services from the provider?

If we pay for more benefits than what we are liable to pay for under this policy, including, but not limited to, benefits paid in error by us, we can recover the excess benefit payments from any person, organization, physician, hospital, or other health care provider that has received such excess benefit payments. We can also recover such excess benefit payments from any other insurance company, service plan, or benefit plan that has received such excess benefit payments.

You may be able to prevent retroactive denials by ensuring that claims submitted are accurate and duplicate submissions are not sent. If a corrected claim is being sent in, please use the corrected claim cover sheet. Please call the Customer Service number listed on your ID card prior to treatment for verification of benefits or following the prior authorization process can also eliminate some retroactive denials.

If a claim is denied, in whole or in part, you will receive written notice of the denial—your Explanation of Benefits—and the reasons for the denial. The notice will also inform you of the right to file a grievance and the procedure to follow. Prior authorization denials will be considered claim denials and will follow the same notification process.

How can an enrollee obtain a refund of premium when he/she overpays?

Enrollees will be refunded any premium overpayment that we receive less any claims paid during the period of time the enrollee was not eligible under the policy (if applicable). Requests for refund of premium overpayment can be made through written or electronic correspondence or by calling Customer Service.

If we cannot recover such excess benefit payments from any other source, we can also recover such excess benefits payments from you. When we request that you pay us an amount of the excess benefit payments, you agree to pay us such amount immediately upon our notification to you. We may, at our discretion, reduce any future benefit payments for which we are liable under this policy on other claims by the amount of the excess benefit payments, in order to recover such payments. We will reduce such benefits otherwise payable for such claims until the excess benefit payments are recovered by us.

What is medical necessity?

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. The definition of medically necessary is a health care service or facility determined to be consistent with and appropriate for the diagnosis or treatment of your illness or injury;

  • Commonly and customarily recognized and generally accepted by the medical profession in the United States as appropriate and standard care for the condition being evaluated or treate
  • Substantiated by the clinical documentation;
  • The most appropriate and cost-effective level of care that can safely be provided to you. Appropriate and cost-effective does not necessarily mean the least expensive;
  • Proven to be useful or likely to be successful, yield additional information, or improve clinical outcome; and
  • Not primarily for the convenience or preference of the covered person, his/her family, or any health care provider.
  • A health care service may not be considered medically necessary even if the health care provider has performed, prescribed, recommended, ordered, or approved the service, or if the service is the only available procedure or treatment for your condition.
What is a prior authorization?

A prior authorization is the process of receiving written approval for certain services or products prior to services being rendered. It is a written form submitted to us by your provider. Services are still subject to all plan provisions including, but not limited to, medical necessity and plan exclusions. Some services may require prior authorization and/or be subject to review for medical necessity.

Are all prior authorization requests subject to review?

Failure to comply with our prior authorization requirements will initially result in no benefits being paid under the Policy. If, however, a health care service is denied solely because you did not obtain our prior-authorization, you can request that we review and reconsider the denial of benefits by following the Internal Grievance and Appeals Procedures outlined in your or the customer’s Policy. If we determine that the health care service would have been covered under this Plan if you had followed the prior authorization process, we will (overturn the denial of benefits) and reprocess the affected claim(s) in accordance with your standard benefits.

Classification of prior requests:
Urgent request: Requests for medical care or services where application of the time frame for making routine or non-life threatening care determinations:
  • Could seriously jeopardize the life, health, or safety of the customer or others, due to the customer’s psychological state, or
  • In the opinion of a practitioner with knowledge of the customer’s medical or behavioral condition, would subject the customer to adverse health consequences without the care or treatment that is the subject of the request.
  • These requests are reviewed within 24 hours of receipt of the request.

Concurrent request: A request for coverage of medical care or services made while a customer is in the process of receiving the requested medical care or services. These requests are reviewed within 72 hours of receipt of the request.

Non-urgent request: A request for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the customer or the customer’s ability to regain maximum function and would not subject the customer to severe pain. These requests are reviewed within 15 calendar days of receipt of the request.

Does prior authorization apply to drugs?

Yes, formulary and non-formulary drugs which are determined to have medical utility, but also require a higher degree of review to determine appropriateness, are required to undergo prior authorization.

  • Criteria for authorization will be established after considering clinical data, reference materials, expert physician opinion, FDA-approved labeling, and/or cost-benefit information.
  • Step therapy (i.e., encouraging the use of certain drugs prior to using others) may be incorporated into these parameters at the discretion of WPS.
  • Practitioners can identify drugs that require prior authorization via our website.
  • Practitioners may request the criteria for their review
  • Determinations will be made by the health plan or its designee.
How are exceptions requested?

Exceptions can be requested by calling 800-417-8164 for drugs managed by the Pharmacy Benefits Manager or 888-515-1357 for specialty drugs. The key pieces of information needed to process an exception request include:

  • Patient name, date of birth, and ID number.
  • Drug(s) requested, reason for use, and duration of treatment.
  • Drug(s) customer has previously tried for this condition and reason for failure.
  • Practitioner name, specialty, telephone, and fax number.
What is the time line for processing of Practitioner Prior Authorization Requests?
  • Timeliness of decision-making
  24 hours 72 hours 14 days 15 days 30 days
Commercial urgent concurrent review        
Commercial urgent prior authorization        
Commercial non-urgent prior authorization        
Commercial post-service decision        
Marketplace urgent prior authorization        
Marketplace non-urgent prior authorization        
Marketplace post-service decision        
  • WPS and its delegates will have processes in place to address urgent requests after normal business hours within the appropriate time frame.
  • Information submitted by the practitioner will be compared to the coverage criteria to render a decision on each request. Once a decision has been rendered, notification of the approval or denial will be sent to the practitioner and customer. For a denial, the customer and practitioner will be informed about how to contact the reviewer to discuss the case.
  • Notification may be either verbal, electronic, or in writing.
  • Notification will follow the time frames identified above in the grid.
  • A denial can only be made by a pharmacist or physician.
  • If the request is denied for medical necessity or as an experimental/investigational treatment, the notification letter will include information about the reason for the denial as well as the appeal and independent review processes. If the request is denied as a plan exclusion, or for any other reason, the notification letter will include information about the reason for the denial and the appeal process.
What is an Explanation of Benefits (EOB)?

An Explanation of Benefits (EOB) is a written explanation of how a medical claim was processed according to your plan benefits. It contains detailed information about what the company paid and what portion of the costs you are responsible for. EOBs are sent after a claim is received and adjudicated.

What does Coordination of Benefits (COB) refer to?

Coordination of Benefits (COB) applies to all health provisions of policies that pay benefits for expenses incurred. COB provisions apply when you have health coverage under more than one plan and eliminate duplication of benefits. The order of benefit determination rules determine which plan will pay as the primary plan. The primary plan pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.


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