Provider Network Participation and Credentialing
- Regardless of funding source (ASO or fully insured), WPS products may use the WPS Health Insurance (Statewide PPO) or WPS Health Plan (SelectPlus HMO/POS) networks.
- There will be no exclusions of existing providers.
- There will be no additional registration or credentialing of practitioners required.
Provider Reimbursement Rates
- All claims will continue to be paid according to the fee schedule contained in the Provider Agreement. The contracted reimbursement rate will be applied to the claim before transitioning that claim to the ASO platform to complete adjudication and payment.
- There will be no change to the claim submission process for ASO group claims. Claims should be submitted to the payor ID or address on the back of the customer ID card. EDI claims will be handled in the same manner as they are currently.
Claims will be adjudicated on Auxiant’s claims platform.
- While some aspects of how claims are administered will change, we will work diligently to minimize any operational impact to providers and customers.
Claims Status and Member Eligibility
- WPS providers will continue to access the WPS provider portal to check claims status, obtain ERA (electronic remittance advice) data, and verify customer eligibility for all claims.
- If you are not currently enrolled in our provider portal, please register. Along with your practice demographics, you will also need to provide information from two recent remittances.
- Separate payment and remittance advice will be issued for each ASO employer group.
Prior Authorization of Covered Services
- WPS will continue to require prior authorization of certain medical care services. This includes the prior authorization of PT/OT/SLP services and imaging services managed by Evolent Health. Some ASO employer groups may choose to require prior authorization of fewer services than WPS fully insured groups require.
- ASO employers may not require authorization of more services or different services than those contained in the WPS Prior Authorization listing published on our website.
Overpayment and Refund Requests
- Because the funds must be returned to the ASO employer’s account, ASO groups will be excluded from WPS’ recoupment processes. Instead, Auxiant will issue a request for overpayment refund to the provider. Your prompt cooperation with this request will be appreciated.
- Providers may notice small differences in coding edits applied to ASO and fully insured groups. For example, some services not typically allowed by WPS may be paid when processed on the ASO platform. WPS has conducted a thorough evaluation of the edits used in the ASO claim platform to ensure that these differences are minor.