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Network Health Insurance Corporation — Provider Manual

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  1. General Information
  2. Credentialing
  3. Care Management
  4. Claims
  5. Evidence of Coverage

i. General Information

  1. NHIC Contact List
  2. Product History
  3. Medicare Advantage Plans
  4. Disclosure of Quality and Performance Indicators to CMS
  5. Consideration of Linguistic and Clutural Needs of Members
  6. Privacy and Confidentiality of Member Information and Records
  7. Business Information Protection
  8. Fraud Waste and Abuse
  9. Prohibition of Health Screening Prior to Enrollment
  10. NHP / NHIC – Access – Practitioner / Plan Standards
  11. Medical Records Review Process
  12. Medicare Required Disclosure of Information to Beneficiaries
  13. Termination of Provider Services
  14. Grievance Resolution Policy and Procedure for Network PlatinumPlus
  15. Network Health Plan / Network Health Insurance Corporation's Grievance Process
  16. Medicare Advantage Plans Financial Affairs and Beneficiary Protections

ii. Credentialing

  1. Credentialing Process
  2. Recredentialing Process
  3. Credentialing Recredentialing Policies and Procedure Review
  4. Site Visit and Medical Recordkeeping Practices
  5. High Volume Specialists Determination Policy and Procedure
  6. Fair Hearing and Appellate Review Process
  7. Range of Actions to Improve Performance / Altering the Conditions of Participation
  8. Reporting to the Proper Authorities
  9. Initial and Ongoing Assessment of Organizational Providers
  10. Process for Ongoing Monitoring of Sanction, Complaints and Quality Issues
  11. Credentials Committee Membership and Responsibility
  12. Delegation and Oversight Policy and Procedure

iii. Care Management

  1. Incentive Policy / Availability of Utilization Management Criteria / Access to NHP/NHIC Care Management Staff
  2. Services Requiring Authorization for PlatinumPlus PPO and PlatinumPremier
  3. PlatinumPlus PPO – Specialty Care Access
  4. Clinical Criteria for Utilization Decisions
  5. Medical Policy Development
  6. Policy on Incentives for Utilization Decisions
  7. CM Staff Accessibility to Members and Practitioners
  8. Notice of Non-Coverage of Inpatient Hospital Care
  9. Notice of Discharge and Medicare Appeal Rights
  10. Termination of Provider Services
  11. Notice of Medicare Non-Coverage Forms
  12. Network Health Plan Outpatient Treatment Report for Behavioral Health Form
  13. Network Health Plan Outpatient Treatment Report for AODA Services – Initial Form
  14. Network Health Plan Outpatient Treatment Report for AODA Services – Concurrent Form

iv. Claims

  1. CMS-1500 Professional Claim Information
  2. UB-04 Uniform Billing Claim Implementation
  3. Claims Mailing Address
  4. Claims Payment for NHP SelectChoice
  5. Provider Claims Appeal Process

v. Evidence of Coverage

  1. 2012 Network PlatinumSelect
  2. 2012 Network PlatinumPlus Pharmacy
  3. 2012 Network PlatinumPremier Pharmacy
  4. 2012 Network PlatinumPlus
  5. 2012 Network PlatinumPremier
  6. 2012 NetworkCares

H5215_Website12 CMS Approved 12152011
Last Updated: 2/20/2012

Notice of Privacy Practices (2012)

Quality Initiatives (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages)
Financial Information | Site Map | Network Health Plan (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages)

Network PlatinumPlus, Network PlatinumPremier and Network PlatinumSelect are Medicare Preferred Organizations (PPO) plans offered by Network Health Insurance Corporation, a Medicare Advantage plan with a Medicare Contract. Benefits, formulary pharmacy network, premium and /or copayments and co-insurance may change on January 1, 2013.The Network Health Insurance Corporation Contract is renewed annually, so enrollment in a plan cannot be guaranteed.

We also offer NetworkCares PPO SNP, a $0 premium full dual eligible Special Needs Plan. NetworkCares is a Coordinated Care Plan with a Medicare Advantage contract and contract with the Wisconsin Medicaid Program. This plan is available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Part B premium unless otherwise paid for by Medicaid or by another third party. For information about this Special Needs Plan, please contact us at 1-800-983-7587 or 1-800-947-3529 Monday through Friday 8 a.m. - 8 p.m. For the hearing impaired, call TDD/TTY 1–800–947–3529.

Network Cares has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 2013/2014. NCQA’s approval is based on a review of NetworkCares Model of Care and is an indicator of compliance with CMS requirements. NCQA’s approval is not an endorsement by CMS and/or NCQA of NetworkCares or the quality of services provided by NetworkCares. NetworkCares will still need to be approved each year by CMS in order to operate. If you have any questions regarding our approval by the NCQA, please contact us at 1-800-378-5234.

You may be eligible for extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week.
  • The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m. Monday through Friday. TTY users should all 1-800-325-0778; or
  • Your State Medicaid Office.

The benefit information provided here is a brief summary, not a comprehensive description of benefits. For more information, please contact the plan.

Network Health Insurance Corporation (NHIC) contracts with a network of providers within the 14 county service area to provide Medicare-covered benefits. Our Network Medicare Advantage plans are open to Medicare beneficiaries eligible by age or disability in the plan’s service area. Our Network Medicare Platinum Plans provide reimbursement for all covered benefits regardless of whether they were received in-network, as long as they are medically necessary. With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers.

Individuals must have both Medicare Part A and Part B to enroll and continue to pay their Part B premiums, unless otherwise paid for by Medicaid or by another third party. Plan benefit maximum limitations, copayments and restrictions may apply. To qualify, you must be a resident of the service area and not have End Stage Renal Disease (ESRD).

Members may enroll only during certain times of the year. If you enroll in one of our Medicare Advantage Pharmacy plans, you must receive your Medicare prescription drug benefit through the plan. Eligible members must use network pharmacies to access their prescription drug benefit except under non-routine circumstances; quantity limitations and restrictions may apply. Our Network Medicare Advantage Pharmacy plans use a formulary, which is a list of preferred drugs covered by the plan.