Appropriate provider appeals include, but are not limited to:
WPS collaborates with National Imaging Associates, Inc. (NIA), a subsidiary of Magellan Health Services, for evidence-based management of outpatient radiology benefits. NIA offers a unique combination of superior clinical expertise in radiology, operational excellence, and financial strength and stability.
With NIA, you can access the Utilization Review Matrix, quick start guide, imaging authorization, resources, and more. Whether you are submitting imaging exam requests or checking the status of ordered exams, you will discover that NIA is an efficient, easy-to-use resource.
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 drugs are reviewed by our partner, Diplomat. Non-specialty drugs that require review are either reviewed by our Pharmacy Benefit Manager, or, in rare instances, WPS.
As noted above, WPS has engaged Diplomat to assist with specialty drug management. Diplomat will review each treatment plan relative to evidence-based guidelines that may include step-therapy protocols. Diplomat 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 Diplomat at 888-515-1357.