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Frequently Asked Questions

Navigating the world of insurance isn't always easy. There are bound to be questions. Below are some frequently asked questions regarding Network Health's State of Wisconsin Group Health Insurance Program.

 

 Prior Authorizations and Referrals

A referral is a written request from your personal doctor (also referred to as a primary care practitioner, or PCP), allowing you to see a specialist or receive specific medical services.
Prior authorization (or prior approval) is the process of getting permission from Network Health to determine if a service, procedure, test or out-of-network provider will be covered by your insurance.
Select services, procedures, tests and out-of-network providers require prior authorization before you receive care. You will receive written notification regarding the approval or denial of the Prior Authorization. If you are unsure if a service, procedure, test or procedure requires prior authorization or a referral, call our member experience team at 844-625-2208 prior to the appointment.
We require prior authorization for autism treatment and all inpatient services for mental health, behavioral health or substance abuse services. For assistance, please contact Network Health’s care management team at 800-236-0208. After hours, call your practitioner or the Network Health Nurse Line.

 

 Care Outside the Service Area

If you are traveling outside the network service area and have a medical emergency that requires a visit to the emergency room or urgent care, get the medical care you need without worrying about your health insurance. Network Health will cover the cost of your visit, excluding any required deductible, coinsurance, or copayment. Follow-up care must be received from an in-network provider unless otherwise approved by Network Health. Please call Network Health at 844-625-2208 or 920-720-1811 to inform us that you have received emergency care outside of the service area as soon as you are able.
A trip to the emergency room is warranted if you experience an injury, a worsening medical condition or illness, severe pain, and/or you feel that your health is in danger if you do not receive care immediately. Call Network Health at 844-625-2208 or contact your personal doctor if you need help determining the appropriate level of care.

Go to urgent care if your symptoms are moderate, but not severe or life-threatening. You may receive urgent care services from a nonparticipating facility, however you will only receive in-network benefits if one of the following is true:

  • You receive the services in the emergency department of a hospital or in a hospital-based urgent care facility, or
  • You receive the services in a nonhospital-based urgent care facility and you provide Network Health notification within 48 hours of receiving the services. Call the Network Health Care Management Department at 800-236-0208 (TTY 800-947-3529) to provide that notification.
  • Call Network Health at 844-625-2208 or contact your personal doctor if you need help determining the appropriate level of care.

 

 Pharmacy and Medications

Any prescription medication that must be picked up at a pharmacy is handled through Navitus.
Any medication that is used by a provider during a hospital visit or stay is covered under your Network Health medical insurance.

Medical Drug Exceptions and Member Responsibilities

A medical drug is a drug that is not self-administered. Rather, it is administered by a doctor or physician. 

Network Health's Pharmacy and Therapeutics Committee determines medication tiering and utilization management criteria based on clinical evidence, safety, cost and national recognized therapeutic guidelines. If your prescribed medication is not covered or partially covered, you or your prescriber can ask us to cover it. This is considered an exception.

Medical drug exceptions can be handled both externally and internally. Exceptions usually require a supporting statement from your prescriber explaining why alternative medications are not sufficient.

Common Medical Drug Exception Reasons

  • The requested drug is not on the formulary
  • The requested drug is part of a step therapy
  • A medical condition or drug interaction exists that may require use of the requested drug
  • The requested drug requires a prior authorization

How to Handle a Potential Medical Drug Exception

  • You can contact customer service at the number listed on the back of your member ID card for a list of similar medical drugs covered by Network Health. 
    • You can share this list with your prescriber and ask for a similar medication. 
  • Next, your prescriber must obtain a prior authorization for the exception. This is necessary to determine medical necessity.
    • Your prescriber can complete a prior authorization electronically or via fax and explain why an exception is required. 
    • Electronic requests can be done through portals such as CoverMyMeds® or ExpressPAth®
    • If the prescriber is unable to submit the request electronically, this paper form can be faxed to Express Scripts. 
    • If your prescriber has questions, he or she can call Express Scripts at 800-209-0981.  

A decision will be made regarding your exception within three business days of receiving all the necessary information–including the supporting prescriber statement. You can request an expedited decision if you or your doctor feel your health could be harmed by a three-day waiting period. If your expedited request is granted, a decision will be provided within 24 hours of receiving your doctor’s supporting statement.

  • If a prior authorization is denied, you can request an internal review by contacting customer service at the number listed on the back of your member ID card. 
    • The customer service representative can help you request an exception to cover your drug–he or she can direct you where to send the request.
    • When requesting an exception, a statement from your prescriber is often necessary to support the request for an exception. 
  • Examples of exceptions include the below.
    • You can ask us to cover your drug, even if it is not on our drug list.
    • You can ask us to remove coverage restrictions or limits on your drug.
    • If the internal review upholds the denial for a coverage exception, you will receive a written denial which will contain a form that you can complete and send back to request an external review by an independent review organization.

 

 Network Health Services

Care management provides personalized coordination of care, access to care, identification of benefits and resources, and condition monitoring to help you get the health care you need, whether you’re dealing with a short-term illness or a more complex diagnosis. Care management begins with a one-on-one conversation with a care manager. If you choose to participate, you will work directly with a care manager to manage your health condition with the ability to opt out at any time by contacting the customer service number on your ID card. Care management is available at no cost to members.
Our condition management team empowers you to take charge of your chronic condition and be the healthiest you can be. Our skilled team of registered nurses engages members in one-on-one health coaching about their ongoing care, provides educational resources and helps build connections to community programs. Condition management is available at no cost to members, and enrollment in the program is voluntary. Individuals who may benefit from condition management services include those who have:
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Heart Disease
  • Stroke

 

 Other Questions

There are two ways to choose or verify a primary care practitioner or personal doctor.
  1. Visit login.networkhealth.com Once signed in, select your name in the upper right corner to view your profile. Select Change my Personal Doctor and follow the steps that appear to select or change your doctor.
  2. Call our member experience team at 844-625-2208.
Complete a form from your provider’s office requesting the transfer of medical records. You may also contact your previous provider to request the transfer. Sometimes there is a fee for the collection or transfer of medical records.

Premium- The monthly payment you make for your health plan.

Deductible - The amount you must pay for covered health care services before Network Health begins to pay

Copayment - A set fee you might pay for a type of health care or a prescription drug. For example, your copayment for a doctor visit could be $20. Once your deductible is met, Network Health pays the rest.

Coinsurance - A set percentage you might pay for a type of health care or a prescription drug. For example, 10 percent coinsurance means you pay 10 percent of the cost. Network Health pays the rest.


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.