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Providers

Interested in becoming a participating Network Health Plan provider?

We have a simple online New Provider Request tool that will get you started on the evaluation process. Just follow this link (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages):

At Network, we are committed to building and sustaining long-term relationships with the providers who serve our mutual communities. This is more than a promise. It is a commitment to the level of service, coverage and care that you, as a professional under oath, make to every patient, every day. That same level of service is also what you can expect from us, when our members are in your care.

To help serve you better, we have included information online and at your fingertips, which you will find valuable in continuing or beginning a successful partnership with Network Health Plans.

  1. GENERAL INFORMATION

    1. Product History
    2. Medicare Advantage Plans
    3. Disclosure of Quality and Performance Indicators to CMS 129
    4. Consideration of Linguistic and Cultural Needs of Members
    5. Privacy and Confidentiality of Member Information and Records
    6. Business Information Protection
    7. Fraud Waste and Abuse
    8. Prohibition of Health Screening Prior to Enrollment
    9. NHP/NHIC - Access - Practitioner Plan Standards
    10. Medical Records Review Process
    11. Medicare Required Disclosure of Information to Beneficiaries
    12. Termination of Provider Services
    13. Grievance Resolution Policy and Procedure for Medicare Advantage Plans
    14. Network Health Plan/Network Health Insurance Corporation's Grievance Process
    15. Medicare Advantage Plans Financial Affairs and Beneficiary Protections

  2. CREDENTIALING

    1. Credentialing and Re-Credentialing Processes

  3. CARE MANAGEMENT

    1. Services Requiring Authorization for Medicare Advantage PPO
    2. NHIC Medicare Advantage Specialty Care Access
    3. Clinical Criteria for Utilization Decisions Provider Authorization Request Process
    4. Medical Policy Development
    5. Policy on Incentives for Utilization Decisions
    6. CM Staff Accessibility to Members and Practitioners
    7. Notice of Non Coverage
    8. Notice of Discharge and Medicare of Provider Services
    9. Termination of Provider Services
    10. Notice of Medicare Non-Coverage Forms
    11. Network Health Plan Outpatient Treatment Report for Behavioral Form
    12. Network Health Plan Outpatient Treatment Report for AODA services- Initial Form
    13. Network Health Plan Outpatient Treatment Report for AODA services - Concurrent Form

  4. CLAIMS

    1. CMS - 1500 Professional Claim Information
    2. UB-04 Uniform Billing Claim Implementation
    3. Claims Mailing
    4. Medicare Provider Payment Dispute and Appeal Rights Process
    5. Waiver of Liability Statement

(We have included helpful tools to assist you in locating content within the PDF. When the PDF opens, simply click on the “Bookmarks” tab – it is the top tab at the left of the panel that displays the PDF content. Then find and click on your topic of interest within the “Bookmarks” panel and the link will take you to the specific pertinent page(s) within the PDF. Alternatively, you can use the “Search” functionality. Just click on the binocular icon in the horizontal toolbar located above the panel that displays the PDF content. That will open a new window that will allow you to enter a search term – then enter your term or phrase and click the “search” button. Your results will appear in a new window below the “search” button.)

For Providers:

Prescription Drug Coverage Determination Process

A request for coverage determination may be initiated in any of the 4 (four) following ways (for fax or mail, please use the "Request For Medicare Prescription Drug Coverage Determination Form" located below):

Phone: 1-800-316-3107
Fax: 1-877-837-5922

Mail:
Attn: Prior Authorization-Part D
Mail Route BL0345
6625 West 78th Street
Bloomington, MN 55439

Email: Medicarepartdparequest@express-scripts.com

*Please include the following information on email requests:

  • Patient First Name:
  • Patient Last Name:
  • Patient Member ID:
  • Patient Date of Birth:
  • Patient Phone Number:
  • Prescriber Name:
  • Prescriber DEA/NPI (Required):
  • Prescriber Address:
  • Prescriber Phone Number
  • Prescriber Fax Number:
  • Medication Requested:
  • Diagnosis:
  • Quantity Requested:
  • Days Supply:
  • Other medications/therapies tried and reason for failure and/or any other information the prescriber feels is important to review

Everyone has the right/responsibility to report possible Fraud, Waste and Abuse issues. You may report anonymously and retaliation is prohibited when you report a concern in good faith. Report issues to your organization’s Compliance Office, or the Compliance Officer of the applicable Plan Sponsor with whom you participate.

To report Fraud, Waste and Abuse issues for the Network Platinum Medicare Advantage Plans, please access the link below or contact the Network Health Insurance Corporation Medicare Compliance Special Investigations Unit at 920-720-1225.

Reporting a Fraud, Waste & Abuse or Non-Compliance Incident

For more information from the State of Wisconsin on Medicaid, please visit the Wisconsin Department of Health Services (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages).

Clinical and Preventive Guidelines:

Preventive Guidelines can be found at: http://www.ahrq.gov/clinic/pocketgd.htm  (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages)

H5215_Website12 CMS Approved 12152011
Last Updated: 1/27/2012

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. From Oct. 15th through Feb. 14th we are available 8 a.m. - 8 p.m., 7 days a week. 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.

A partnership of Ministry Health Care and Wheaton Franciscan Healthcare.