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Individual and Family Plans

Understanding Your Coverage

Balance Billing

Balance billing occurs when a provider bills you for the difference between the charged amount and the maximum out-of-network allowable amount. For example, if the provider’s charge is $100 and the maximum allowed amount is $70, the provider may bill you for the remaining $30. You can’t be balance billed by an in-network provider.

Coordination of Benefits (COB) 

COB is available to you and allows you to manage your benefits when you and other members of your plan are covered by more than one health insurance plan. If COB applies, the order of benefit determination rules shall be looked at first. The rules explain whether the benefits of your Network Health plan are determined before or after those of another plan. This would include group insurance or coverage under a governmental plan that is required or provided by law (excluding Medicaid and Medicare).

Drug Exceptions and Member Responsibilities

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.

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 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 Exception

  • You can contact customer service at 855-275-1400 for a list of similar drugs covered by Network Health. 
    • You can share this list with your prescriber and ask for a similar medication. 
    • Network Health formulary drugs are often less expensive and easier to obtain than non-formulary drugs.
  • 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 you or your prescriber have questions, you can call Express Scripts at 800-417-8164.  

Express Scripts will make a decision on 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, Network Health will provide a decision 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 855-275-1400. 
    • 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.

Explanation of Benefits (EOB)

An EOB is a statement sent to you listing health care services you received, the amount billed and payment made. An EOB is sent to you shortly after Network Health receives information from your provider and processes a claim. It is important to review your EOBs and compare them to any provider bills you receive. The amount you owe for an item or service will be shown in the “Your Responsibility” section.

Network Health sends EOBs on an ongoing basis as claims are processed. You may opt to receive electronic delivery of your EOBs by changing your communication preferences in your online member portal.

Grace Periods and Pending Claims

After you have paid your first month’s premium, there is a grace period before Network Health can terminate your coverage if you do not pay your future premiums by the due date.

There are two separate grace periods. 
  1. If you are receiving an advance premium tax credit (APTC), you have a grace period of three consecutive months. Network Health will pay for care received during the first month of the grace period if you are receiving an APTC. However, during the second and third months of the grace period, we will withhold (pend) payment for claims until you pay all outstanding premiums. If full premium payment is not received, your coverage will end on the final day of the first month of the grace period. If your coverage is terminated for failure to make all premium payments in full, you are responsible for paying any medical expenses incurred during the second and third months of the grace period. Once your coverage has been terminated, you will not be able to re-enroll in a Marketplace Qualified Health Plan (QHP) until the next open enrollment period. The only exception is if you qualify for a special enrollment period. Losing coverage because you did not pay your premium does not qualify you for special enrollment period.
  2. If you are not receiving an APTC, your grace period is 31 days. If you are not receiving APTC and have paid your first month’s premium, Network Health will allow a grace period of 31 days following your premium due date to pay monthly premiums that are past due. During the grace period, your coverage will remain effective. No benefits are payable for expenses incurred during the grace period if the premium payment has not been received by the end of the grace period. If you fail to pay your premium during the grace period, your coverage will terminate at end of the period for which the last full premium payment was made.

The grace period doesn’t apply if your policy terminates for any reason other than not paying your premium.

Medical Necessity

Health care services or supplies are considered reasonable, medically necessary and/or appropriate when:

  • Appropriate and necessary to identify, diagnose or treat bodily injury or illness;
  • Appropriate for and consistent with the diagnosis in accord with generally accepted standards of the medical community;
  • Not primarily custodial care, maintenance therapy or habilitative services;
  • Provided in the least intense, most cost-effective setting or manner needed for your bodily injury or illness;
  • They could not have been provided in a doctor’s office if the services or supplies are institutional care;
  • Not primarily educational in nature;
  • Not for your vocation, comfort, convenience, exercise, physical fitness or recreation;
  • Not to improve the appearance of you or for the convenience of the provider.

Out-of-Network Liability

Except for emergency health and urgent care services, you must get prior authorization from Network Health for services performed by an out-of-network provider to be covered. A maximum out-of-network allowable amount may be applied when services are received from provider who is out-of-network.

Prior Authorization

In some cases, Network Health needs to give approval for you to receive coverage for certain services. This is called a prior authorization (or prior approval). Network Health participating providers will submit a request on your behalf for authorization. If you wish to receive coverage for services from a non-participating provider or a non-participating practitioner in our service area, you must obtain prior authorization from Network Health, except for emergency health services. Failure to do so will result in a denial of benefits.

Network Health will review prior authorization request and make the decision to approve or deny the service based on whether the service is medically necessary and appropriate. Network Health will review the request within 14 days (72 hours for pre-service urgent requests and 24 hours for concurrent urgent requests) and send you a decision letter.

If you have an authorization request or questions about the prior authorization process, call our care management department at 800-236-0208 or TTY 800-947-3529. For mental health and substance abuse services, please contact Network Health’s Care Management Behavioral Health Department at 800-555-3616.

Recoupment of Overpayments

If you feel you are entitled to a refund of premium, submit your request to Network Health in one of the following ways.

  • Call Network Health at 877-549-8793
  • Request a refund by writing to:
    • Network Health
      Attn: Manager, Accounts Receivable
      1570 Midway Place
      Menasha, WI 54952

Retroactive Denials

A retroactive denial is a reversal of a previously paid claim.

To avoid retroactive denials, you should pay premium your no later than 31 days after the due date.

Claims may be reprocessed retroactively up to 15 months from the date the provider was paid. Reprocessing may occur if you and/or the provider were overpaid or underpaid. The provider is responsible for reimbursing you if the new claim entitles you to a credit.

  • Two exceptions to the 15-month limitation are listed below.
    • Claim reversals due to situations involving fraud, waste or abuse.
    • Claim reversals due to member loss of eligibility (an example would be claims paid before notification of retro term of eligibility). 

Notification will be sent to you if the reversal is because of an error in the setup of a benefit and claims need to be reprocessed or new Summary of Member Responsibility Tables (SOMRs) needs to be sent.

If the reversal is due to an error in the provider contract or provider configuration, claims are required to be reprocessed. If necessary, the provider will be notified. You have one year from the proof of loss date to request review. Claims will be reprocessed regardless of the impact of your liability.

Submitting Claims

Network Health processes claims according to state and federal time frames. Providers will file most claims, but if a member files a claim, he or she must provide all reasonably necessary information in order for the claim to process. Providing all the necessary information will allow Network Health to process the claim more quickly. If you have questions about benefits, eligibility or claims payment please call 855-275-1400.

When submitting a claim, please follow these guidelines.

  • Claims must be submitted in English.
  • Claims must be in writing.
  • Claims must be submitted within 90 days of when the service was performed. If it is not reasonably possible to submit the claim within the 90 days, Network Health will accept it until one year after that 90 days.

Network Health does not require a form to submit a claim. To arrange for reimbursement, send itemized bills and proof of payment within 90 days to Network Health.

Claims can be mailed to:
Network Health
Attn: Claims Department
P.O. Box 120
Menasha, WI 54952

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

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