Appropriate provider appeals include:
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 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.
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 balance billed.
A provider can initiate a specialty drug authorization by calling Express Scripts at 800-475-1954.
Under Sec. 111 in the H.R. 133, the Consolidated Appropriation Act, health plans are required to send patients an Advance Explanation of Benefits (AEOB) after receiving a good faith estimate notification from a provider or facility that an individual is scheduled to receive an item or service. In addition, 2009 Wisconsin Act 146 requires hospitals, insurance plans, and health care providers to disclose information about the cost and quality of health care services. Complete the request form to obtain an estimate of out-of-pocket expenses for the member.