A preferred provider is one who has contracted with WPS to provide services to our customers for specific pre-negotiated rates. A non-preferred provider is one who has not contracted with WPS. Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to a non-preferred provider. While there are some exceptions, in many cases, WPS will either pay less or not pay anything for services you receive from non-preferred providers. As a general rule, Preferred Provider Organization (PPO) plans make use of provider networks. Some exceptions to out-of-network liability would be lab work, radiology, or pathology sent from your in-network doctor or facility to an outsourced facility that is out-of-network. Since the customer does not have control over where labs or pathology are being sent, we would allow at the in-network benefit level.

At the written request of our customers, WPS will provide a good faith estimate of the reimbursement WPS will expect to pay and the customer’s responsibility (out-of-pocket costs) for the specified health care service being considered. This process does not take the place of a prior authorization, prior approval, or pre-certification.

Please be aware that any requested pre-service estimate is a verification of benefits and not a guarantee of payment. Payment is based on the terms, conditions, and provisions of the policy/plan and is subject to the provider’s contracted rates in effect at the time the service is performed including, but not limited to:

• Requirements for medical necessity
• Prior authorization
• Pre-certification
• Exclusions for work-related injury
• Provider network affiliation
• Pricing adjustments due to negotiated transplant coverage
• Medical claim coding guideline

Maximum out-of-network allowable feel levels will apply to non-preferred providers and services rendered. This means enrollees are responsible for any charge that exceeds the maximum out-of-network allowable fee level for authorized services received from non-preferred providers. The amount the plan pays for covered services is based on the maximum allowable fee. If a non-preferred provider charges more than the maximum out-of-network allowable fee, you may have to pay the difference. For example, if a non-preferred hospital charges $1,500 for an overnight stay and the maximum out-of-network allowable fee is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

Maximum out-of-network allowable fee levels will apply to non-preferred providers and services rendered. This means enrollees are responsible for any charge that exceeds the maximum out-of-network allowable fee level for authorized services received from non-preferred providers. Also, the estimate of out-of-pocket expenses that will be prepared is based on information submitted to WPS, along with claims and benefits we have processed at the time of our inquiry response. WPS will assume no modifications or complications occur in the treatment plan.

After health care services are provided to you, a claim must be correctly submitted to us. The claim can be submitted by you or the health care provider. Preferred providers will handle the coding and submission of claims on your behalf.

For non-preferred providers who do not code and/or submit claims, the following information must be filed with us within the time frame specified in your health plan.

• Claim forms (including the coding of the health care service, date of the health care service, name of the health care provider, place of service and billed charges) and any relevant documents received from the health care provider at the time of the health care service, and proof of payment.

Covered persons who receive health care services in a country other than the United States will need to pay for expenses up front and then submit the claim to us for reimbursement. We will reimburse you for any covered amount in U.S. currency. The reimbursed amount will be based on the U.S. equivalency rate that is in effect on the date you paid the claim or on the date of service if paid date is not known.

Enrollee claim submission time frames are specific to the health plan. Enrollees can submit any type of form as a claim as long as it meets the criteria below:

• Claims should be itemized and state the provider of the service, diagnosis, date of service, services provided, and amount charged for the services. Please also submit a receipt if you have already paid for the service.

Enrollees who are enrolled in coverage but fail to make premium payment by the assigned due date have a grace period before their coverage can be terminated. The grace period is set by state law. Generally, if you pay your premiums on a monthly basis the grace period is 10 days, if you pay quarterly or yearly the grace period is 31 days.

Claim pending means the issuer has not yet paid the medical claim.

If we pay for more benefits than what we are liable to pay for under a health plan, including, but not limited to, benefits paid in error by us, we can recover the excess benefit payments from any person, organization, physician, hospital, or other health care provider that has received such excess benefit payments. We can also recover such excess benefit payments from any other insurance company, service plan, or benefit plan that has received such excess benefit payments.

You may be able to prevent claim denials by ensuring that claims submitted are accurate and duplicate submissions are not sent. If a corrected claim is being sent in, please use the corrected claim cover sheet. Please call Member Services at 800-332-3297 prior to treatment for verification of benefits. Following the prior authorization process can also eliminate some claim denials.

Enrollees will be refunded any premium overpayment that we receive less any claims paid during the period of time the enrollee was not eligible under the policy (if applicable). Requests for refund of premium overpayment can be made through written or electronic correspondence or by calling Member Services.

If we cannot recover such excess benefit payments from any other source, we can also recover such excess benefits payments from you. When we request that you pay us an amount of the excess benefit payments, you agree to pay us such amount immediately upon our notification to you. We may, at our discretion, reduce any future benefit payments for which we are liable under your health plan on other claims by the amount of the excess benefit payments, in order to recover such payments. We will reduce such benefits otherwise payable for such claims until the excess benefit payments are recovered by us.

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Generally the definition of medically necessary is a health care service that we determine to be:

1. Consistent with and appropriate for the diagnosis or treatment of your illness or injury;
2. Commonly and customarily recognized and generally accepted by the medical profession in the United States as appropriate and standard of care for the condition being evaluated or treated;
3. Substantiated by the clinical documentation;
4. The most appropriate and cost-effective care that can safely be provided to you. Appropriate and cost effective does not necessarily mean the least expensive;
5. Proven to be useful or likely to be successful, yield additional information, or improve clinical outcome; and
6. Not primarily for the convenience or preference of the covered person, his/her family, or any health care provider.

A health care service may not be considered medically necessary even if the health care provider has performed, prescribed, recommended, ordered, or approved the service, or if the service is the only available procedure or treatment for your condition.

What is a prior authorization?

A prior authorization is the process of receiving written approval for certain services or products prior to services being rendered. It is a written form submitted to us by your provider. Some services may require prior authorization. Please see the prior authorization list. All services including those prior authorized by us are subject to all plan provisions including , but not limited to, medical necessity and plan exclusions.

Are all prior authorization requests subject to review?

Failure to comply with our prior authorization requirements will initially result in no benefits being paid under the Policy. If, however, a health care service is denied solely because you did not obtain our prior-authorization, you can request that we review and reconsider the denial of benefits by following the Internal Grievance and Appeals Procedures outlined in your or the customer’s health plan. If you prove to us that the health care service would have been covered under the health plan if you had followed the prior authorization process, we will overturn the prior authorization penalty and reprocess the affected claim(s) in accordance with the health plan's standard benefits.

Classification of prior authorization requests:
Urgent request: Requests for medical care or services where application of the time frame for making routine or non-life threatening care determinations:
• Could seriously jeopardize the life, health, or safety of the customer or others, due to the customer’s psychological state, or
• In the opinion of a practitioner with knowledge of the customer’s medical or behavioral condition, would subject the customer to adverse health consequences without the care or treatment that is the subject of the request.
• These requests are reviewed within 24 hours of receipt of the request.

Concurrent request: A request for coverage of medical care or services made while a customer is in the process of receiving the requested medical care or services. These requests are reviewed within 72 hours of receipt of the request.

Non-urgent request: A request for medical care or services for which application of the time periods for making a decision does not jeopardize the life or health of the customer or the customer’s ability to regain maximum function and would not subject the customer to severe pain. These requests are reviewed within 15 calendar days of receipt of the request.

Yes, formulary and non-formulary drugs which are determined to have medical utility, but also require a higher degree of review to determine appropriateness, are required to undergo prior authorization.

• Criteria for authorization will be established after considering clinical data, reference materials, expert physician opinion, FDA-approved labeling, and/or cost-benefit information.
• Step therapy (i.e., encouraging the use of certain drugs prior to using others) may be incorporated into these parameters at the discretion of WPS.
• Practitioners can identify drugs that require prior authorization via our website.
• Practitioners may request the criteria for their review
• Determinations will be made by the health plan or its designee.

Exceptions can be requested by calling 800-753-2851 for drugs managed by the Pharmacy Benefits Manager or 888-515-1357 for specialty drugs. The key pieces of information needed to process an exception request include:

• Patient name, date of birth, and ID number.
• Drug(s) requested, reason for use, and duration of treatment.
• Drug(s) customer has previously tried for this condition and reason for failure.
• Practitioner name, specialty, telephone, and fax number.

• Timeliness of decision-making

• WPS and its delegates will have processes in place to address urgent requests after normal business hours within the appropriate time frame.
• Information submitted by the practitioner will be compared to the coverage criteria to render a decision on each request. Once a decision has been rendered, notification of the approval or denial will be sent to the practitioner and customer. For a denial, the customer and practitioner will be informed about how to contact the reviewer to discuss the case.
• Notification may be either verbal, electronic, or in writing.
• Notification will follow the time frames identified above in the grid.
• A denial can only be made by a pharmacist or physician.
• If the request is denied for medical necessity or as an experimental/investigational treatment, the notification letter will include information about the reason for the denial as well as the appeal and independent review processes. If the request is denied as a plan exclusion, or for any other reason, the notification letter will include information about the reason for the denial and the appeal process.

An Explanation of Benefits (EOB) is a written explanation of how a medical claim was processed according to your plan benefits. It contains detailed information about what the company paid and what portion of the costs you are responsible for. EOBs are sent after a claim is received and adjudicated.

Coordination of Benefits (COB) applies to all health provisions of policies that pay benefits for expenses incurred. COB provisions apply when you have health coverage under more than one plan and eliminate duplication of benefits. The order of benefit determination rules determine which plan will pay as the primary plan. The primary plan pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so that payments from all plans do not exceed 100% of the total allowable expense.