Provider Resources

June 2019

Table of Contents

Authorization for Cardiology, Spine Removed for Medicare

Updated Drug List Published for ESI Care Continuum (CCUM)

Retail Pharmacy Network to Transition from CVS to Walgreens

Updates Posted to Claims Policies and Procedures

CPT and HCPCS Code Updates Effective July 1

 

Authorization for Cardiology, Spine Removed for Medicare

Effective July 1, 2019, Network Health will remove the prior authorization requirements for all spine and cardiology procedures with eviCore for our Medicare population only.

The spine and cardiology programs that no longer require authorization for Medicare members include the following services. Services performed on or after July 1 will not require prior authorization from eviCore. 

  • Cardiac diagnostics, including diagnostic cardiac catheterizations, nuclear cardiology scans, stress echocardiograms, transesophageal echocardiograms, transthoracic echocardiograms
  • Implantable spinal neurostimulator insertion, revision or removal procedures
  • Cervical, lumbar and thoracic spine surgeries

Authorization requirements with eviCore’ spine and cardiology programs will continue for all Network Health commercial lines of business. A list of all services that require prior authorization from eviCore is available at www.evicore.com/implementation/healthplan/network-health-wisconsin.

For more information about authorization requirements, forms or lists of services that require review, visit the Authorization Information section of our.

For prior authorization requests, or if you have specific questions regarding a service, contact our population health department Monday-Friday from 8 a.m. to 5 p.m.

Medicare:  Call 920-720-1602 or 866-709-0019
Commercial: Call 920- 720-1600 or 800-236-0208

For assistance with a predetermination request for Medicare cardiac or spine procedures contact our utilization management team at 920-720-1602 or 866-709-0019.

Please forward this information to those within your facility who will need to follow these processes. 

Language assistance is available for members or practitioners to discuss utilization management issues. Network Health also offers TDD/TTY services for deaf, hard of hearing or speech-impaired individuals. Anyone who needs these services should call 800-947-3529. All callers may leave a message 24 hour a day, seven days a week..

 

Updated Drug List Published for ESI Care Continuum (CCUM)

On June 21, Network Health published an updated list of medical drugs that require prior authorization through ESI Care Continuum (CCUM). The most recent update is effective July 21, 2019.

This list will continually update throughout the year to remain in alignment with the evolving pharmaceutical marketplace.

The current and upcoming lists have been combined in one document to keep you informed in advance of any changes. The document currently includes the lists for the following effective dates. 

Effective July 21, 2019
Effective July 1, 2019
Effective May 1, 2019

The document also includes links to help you navigate the lists by effective date.

Retail Pharmacy Network to Transition from CVS to Walgreens

On January 1, 2020, Network Health will transition to Express Scripts (ESI) as the pharmacy benefits manager for all lines of business. ESI has provided pharmacy benefits management for Network Health Medicare members since 2005. Through the transition, the major retail pharmacy network will switch from CVS/caremark™ to Walgreens.

For our members’ convenience, Network Health will provide access to Walgreens pharmacies beginning August 1, 2019. CVS/caremark™ will continue to be in-network until December 31, 2019. This gives you and your patients time to work with a Walgreens pharmacist to transition pharmacy files from CVS/caremark™ (or any pharmacy).

If members decide not to participate in the early transition to Walgreens, we have advised them to refill prescriptions the last week of December 2019 to cover their medication needs until they can transfer their pharmacy files to an in-network pharmacy on January 1, 2020.

Members and providers can search the entire updated pharmacy network, both retail and mail order, through Find a Pharmacy starting November 1, 2019.


Updates Posted to Claims Policies and Procedures

We have posted new procedures and policy changes for claims that will go into effect July 28, 2019. Based on feedback from providers, we have combined a few policies and have created several new procedures to clarify processes.

The new polices are located under Claims Policies and Procedures include the following procedures.

  • Correcting Provider Overpayments and Underpayments
  • Subrogation
  • Contract Pricing Updates
  • Bill Audit Review
  • Emergency Observation Inpatient Copayment

CPT and HCPCS Code Updates Effective July 1

Quarterly, the American Medical Association updates Current Procedural Terminology (CPT) codes and the Centers for Medicare and Medicaid Services updates Healthcare Common Procedure Coding System (HCPCS) codes. 

Effective July 1, there are new codes that will require prior authorization, and these services fall within our current authorization, experimental and/or genetic review processes. For more information about authorization requirements, forms or lists of services that require review, visit the Authorization Information section of our website.

For prior authorization requests, or if you have specific questions regarding a service, contact our population health department Monday-Friday from 8 a.m. to 5 p.m.

Medicare:  Call 920-720-1602 or 866-709-0019
Commercial: Call 920- 720-1600 or 800-236-0208.

For questions specific to behavioral health utilization, call 920-720-1340 or 800-555-3616. 

Please forward this information to those within your facility who will need to follow these processes. 

Language assistance is available for members or practitioners to discuss utilization management issues. Network Health also offers TDD/TTY services for deaf, hard of hearing or speech-impaired individuals. Anyone who needs these services should call 800-947-3529. All callers may leave a message 24 hour a day, seven days a week.

 

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