Provider Resources

Medical and Pharmacy Policies Disclaimer

Medical and Pharmacy Policies Disclaimer

Please read before continuing:

Affirmative Statement Regarding Incentives

Integrated Care Management decision-making at WPS Health Insurance and WPS Health Plan is based solely on appropriateness of care and existence of coverage. WPS Health Insurance and WPS Health Plan does not reward practitioners or other individuals for issuing denials of coverage. Financial incentives for Integrated Care Management decision-makers do not encourage decisions that result in underutilization.


To find Medical Policy guidelines for a patient covered by Medicare, go to the WPS Government Health Administrators website.

Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in these policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs Medical Policies in all their coverage determinations. Contact Customer Service as listed on the customer card for specific plan, benefit, and network status information.

Medical Policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health, to assist in administering health benefits. These medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

For specific patient-related policy or medical coding inquiries, please contact WPS Medical Affairs at 800-333-5003 with the applicable patient name and customer number, along with the procedure, service, or treatment in question.

We welcome your feedback regarding medical policies or MCG Health guidelines.
For questions or comments regarding research and evidence development of a specific criteria, general medical policy, or MCG Health questions, contact the Medical Policy Committee at To request an assessment of  new technology or medical policy criteria by the Medical Policy Committee, please complete the New Technology and Medical Policy Assessment Request Form, attach supporting documentation from peer-reviewed high-level scientific literature, and email to the committee at

For questions regarding medical coding related to policies, contact the Code Governance Committee at

NOTE: The email addresses above should NOT be used to send personal health records or customer identified information.

This disclaimer applies to all past and present medical and pharmacy policies.

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