Provider Resources

• Has the service level for your patient been determined?
  (Intensive vs. Non-intensive) Please download, fill out, and return the Autism Spectrum Progress Report form.
• Autism Attestation Notification Form.

• Corrected Claim Form
• Family Care/CLTS Corrected Claim Form Tip Sheet
• Family Care/CLTS Corrected Claim Form

This provides a collection of HIPAA forms and documents, particularly those regarding personal health information (PHI).

• More Information on HIPAA
• Notice of Privacy Practices
• Appeals/Grievance Authorized Representative Form
• Authorization for WPS to Disclose Health Information
• Confidential Communications
• Consent to Unsecure Email Communication
• Request to Access PHI
• Request to Amend PHI
• Instructions for Completing the Member Authorization Form
• Privacy Complaint Form

• How to Become a WPS Health Insurance Provider
• If you are a chiropractic provider interested in joining our network, please contact Magellan Healthcare at 952-225-5732.

• Neuropsychological Testing Request Form
• Outpatient Behavioral Health Treatment Request Form
• Outpatient Behavioral Health Treatment Request Form - WPS Employee Group
• Outpatient Behavioral Health Treatment Request Form - Instructions

• Kidney Dialysis Prior Authorization Request Form
• Outpatient Therapy Prior Authorization Request Form
• Prior Authorization and Referral Request Form

• Provider Appeal Form

• Practitioner Data Sheet
• Facility Data Sheet
• W9 Form
  
  Submit W9 Form

WPS Health Insurance 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.

Create an account today!

• NIA 2019 Utilization Matrix Effective 1/2/2019

• Refund Form