Provider Manual TABLE OF CONTENTS INTRODUCTION Aspirus Arise is pleased to welcome you as a partner! Introduction ...................................................................................................................................................3 The Aspirus Arise Provider Manual is designed and produced for Aspirus Arise Contact Aspirus Arise ................................................................................................................................4 providers to promote a clear understanding of our policies and procedures, About Aspirus Arise ....................................................................................................................................5 including provider services, outpatient prior authorization, claims, and eligibility. Product and Benefit Plans ........................................................................................................................6 The purpose of this manual is to answer some of the questions you may Member Primary Care Access Model .................................................................................................... 7 have regarding Aspirus Arise operations. As changes occur, this manual will be updated on a routine basis. Aspirus Arise reserves Appointment Scheduling Guidelines .....................................................................................................8 the right to revise or alter the material and information detailed in Medical Record Requirements ................................................................................................................9 this manual at any time. Medical Management ..........................................................................................................................10-11 Medical Management Program ..............................................................................................................12 Medical Management Definitions .................................................................................................... 13-14 Prior Authorization ...............................................................................................................................15-16 Prior Authorization Determination .........................................................................................................17 Special Programs/Provider Responsibility ......................................................................................... 18 Vision Management............................................................................................................................18-20 Concurrent Review Decisions................................................................................................................ 21 Post-Service Determination .................................................................................................................. 22 Case Management ............................................................................................................................ 23-24 Chronic Disease Management ............................................................................................................ 25 Behavioral Health Management ....................................................................................................26-28 Chiropractic Care Management ........................................................................................................... 29 Pharmacy Management ....................................................................................................................30-31 Drug Prior Authorization ..........................................................................................................................32 Technology and Incentives .....................................................................................................................33 Resources/Tools .................................................................................................................................34-35 Medical Policy Guidelines ...................................................................................................................... 36 Quality Improvement Program ..............................................................................................................37 Urgent and Emergent Care .............................................................................................................38-39 Telemedicine ............................................................................................................................................. 40 Member Rights and Responsibilities ....................................................................................................41 Member Grievance Procedures ............................................................................................................42 Claims Procedures .............................................................................................................................43-45 Provider Rights to Pertaining Credentialing ..................................................................................... 46 Continuity of Care .....................................................................................................................................47 Provider Contracting ............................................................................................................................... 48 2 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 3 CONTACT ASPIRUS ARISE ABOUT ASPIRUS ARISE On Jan. 27, 2016, Aspirus and WPS Health Solutions announced the creation of a new health insurance company, Corporate Aspirus Arise Health Plan of Wisconsin, Inc., known publicly as Aspirus Arise, in north-central Wisconsin. Aspirus Phone 715-972-8140 Arise offers individual marketplace, small group, large group, and self-funded plans for 2017 effective dates. Email [email protected] Aspirus is a non-profit, community-directed health system based in Wausau, Wisconsin. With more than 7,000 Website AspirusArise.com employees, Aspirus serves communities throughout 16 counties in northern and central Wisconsin, as well as Mailing Address Aspirus Arise the western Upper Peninsula of Michigan. The integrated system includes four hospitals in Michigan and four P.O. Box 395 hospitals in Wisconsin, 50 clinics, more than 400 physicians, home health and hospice care, pharmacies, critical Wausau, WI 54402 care and helicopter transport, medical goods, nursing homes, and high-quality affiliated physicians. Electronic Claim Submission WPS Health Solutions is a nationally regarded government contractor and a leading Wisconsin not-for-profit The WPS Electronic Data Interchange (EDI) department has a dedicated staff whose primary function is to consult health insurer. The WPS Health Insurance division offers affordable individual health insurance, family health and service providers on electronic processes. Our staff is experienced in dealing with a variety of provider insurance, high-deductible health insurance, and short-term health plans, as well as flexible and affordable group specialties, billing services, and software vendors. plans and cost-effective benefit plan administration for businesses. The WPS Government Health Administrators division administers Part A and B Medicare benefits for millions of seniors in multiple states, and the WPS Military Phone 608-221-7115 and Veterans Health division serves millions more who are active in the U.S. military, veterans, and their families. Toll-Free 800-782-2680 In 2017, the International Ethisphere® Institute named WPS one of the World’s Most Ethical Companies® for the Email [email protected] eighth straight year. For more information about WPS, visit wpsic.com. Hours Monday–Thursday, 7 a.m. to 10 p.m. Friday, 7 a.m. to 4:30 p.m. Saturday, 8 a.m. to noon Claim Submission Aspirus Arise SERVICE AREA P.O. Box 21684 Eagan, MN 55121 Medical Management Phone 920-490-6901 Toll-Free 800-332-3297 (follow prompts 2, 4, 2) Fax 920-490-6943 Contact Medical Management for: · Pharmacy management · Medical policies · iExchange electronic prior authorization request · Outpatient prior authorization guidelines · Inpatient prior authorization guidelines (inpatient hospital or skilled nursing facility) Network Management, Provider Relations, and Provider Credentialing Phone 715-972-8140 Email [email protected] Hours Monday–Friday, 8 a.m. to 4:30 p.m. Contact Network Management, Provider Relations, and Provider Credentialing for: · Provider additions, terminations, and changes · Fee schedule questions · Assistance with provider issues · Provider directory/website listings · Credentialing questions 4 | Aspirus Arise Provider Manual Aspirus Arise Provider Manual | 5 PRODUCT AND BENEFIT PLANS ID CARDS Aspirus Arise offers a broad range of insurance products to meet the needs of our group and individual customers, from traditional Health Maintenance Organization (HMO) and Point-of-Service (POS) plans, to self- funded administration and consumer-driven options. Aspirus Arise is a Qualified Health Plan Issuer in the Health Insurance Individual Marketplace and SHOP (Small Business Health Options Program), offering its plans on- and off-Marketplace. INDIVIDUAL AND FAMILY PLANS Aspirus Arise also offers a wide variety of individual products providing exceptional flexibility and value for individuals. Individuals can choose from POS plans and HMO plans,