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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.
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. To learn more about care management, call 800-378-5234 (TTY 800-947-3529) Monday–Friday, from 8 a.m. to 5 p.m.
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.
- 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.
- 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.
