Submission and Verification

Prior authorization requests should be submitted by providers via iExchange (preferred). Fax submissions accepted at 608-226-4777. Prior Authorization forms are available online at wpshealth.com/resources/provider-resources/forms-documents.shtml. Providers must verify customer eligibility and benefits through the WPS Provider Portal or by calling Customer Services at 800-765-4977. For questions, use the contact information on the customer ID card or call Customer Services if the ID card is unavailable.

• Preferred submission: iExchange (see wpshealth.com/resources/provider-resources/iexchange/overview.shtml)
• Fax alternative: 608-226-4777
• PA forms: wpshealth.com/resources/provider-resources/forms-documents.shtml
• Verify eligibility/benefits: WPS Provider Portal or 800-765-4977
• Contact for PA questions: number on customer ID card or Customer Services 800-765-4977

Inpatient Admission Notification

Notification/prior authorization is required for planned (elective/scheduled) inpatient admissions (hospital, behavioral health, SNF, LTAC, inpatient rehabilitation, inpatient hospice). The health plan must be notified and a prior authorization request submitted at least three days prior to the planned admission date. For urgent or emergent admissions, notification to the health plan must be made within two days of the admission (sooner if possible).

• Planned inpatient admissions: notify/submit PA a minimum of 3 days prior to admission
• Urgent/emergent admissions: notify within 2 days of admission (sooner if possible)
• Applies to: Hospital, Behavioral Health, Skilled Nursing Facility (SNF), Long-term Acute Care (LTAC), Inpatient Rehabilitation, Inpatient Hospice

Therapy Prior Authorization Process

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) require verification of benefit coverage prior to services. Authorization requests should be faxed to 608-226-4777. Medical necessity review is performed after specified visit thresholds: PT after 10 visits, and after 8 visits for OT and ST. Coverage varies by group—verify the customer's benefit plan before rendering services. For Speech Therapy reviews, MCG guidelines are used.

• Fax authorization requests to: 608-226-4777
• Medical necessity review thresholds: PT = 10 visits; OT/ST = 8 visits
• Verify benefit coverage prior to services; coverage varies by group
• Speech Therapy reviews utilize MCG guidelines
• Reference: physical and occupational therapy medical policy

Specialty Services Prior Authorization Notes

Specialty services often require prior authorization and/or verification of plan coverage. Examples include durable medical equipment (DME), orthotics, home medical devices, ventilators, transplant services, non-emergency transport, and other high-cost or specialized services. Dollar thresholds and always-required items vary by plan—contact Customer Services to confirm the applicable thresholds and coverage rules.

• DME/Orthotics: typical PA thresholds — rentals above $750/month or purchases above $1,000; some plans may have different thresholds (verify with Customer Services)
• Certain orthotics and DME always require prior authorization regardless of cost (examples: CPAP/BiPAP machine purchases)
• Specific DME that commonly require PA: heated humidifiers for PAP devices, home ventilators, home negative pressure wound therapy (wound vac), home pneumatic compression devices, wearable cardiac defibrillator vests, tumor treatment field devices (e.g., Optune®)
• Prosthetics: PA required for prosthetics over $5,000; microprocessor and myoelectric-controlled prosthetics require PA regardless of cost
• Ventilators: PA required for home use
• Transplants: verify plan coverage and obtain PA as indicated
• Non-emergency patient transport (MediVan, ground or air ambulance): prior authorization required
• Radiation/proton and other advanced radiation services: use evicore (preferred) or call 800-475-1954; fax 800-540-2406