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Provider Resources

Forms

Below you will find up-to-date forms for submission to Network Health or third-party partner organizations. Please check this page often as some forms are updated annually. 

Activity Level of Care Form (ALOC – SNF Facility)
Notice of Medicare Non-Coverage Form (Home Health Care)
Notice of Medicare Non-Coverage Form (Skilled Nursing Facility)
Recoupment Request Form
Authorization Request Form


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.

Copyright 2024 Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. Network Health Cares is a PPO D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. Each year, Medicare evaluates plans based on a 5-Star rating system. Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Y0108_4790-01-0923_2024_D Last Updated Jul 29, 2024 2:21 PM

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