How Health Plans Make Decisions

Did you know that utilization decisions made about your care by Network Health plan are based on the appropriateness of care and service?

Care and service include medical procedures, behavioral health procedures, pharmaceuticals and devices. Decisions are based on written criteria founded on sound clinical evidence and on the benefits outlined in your Coverage document. The written criteria are reviewed and approved annually by actively-participating practitioners. Criteria are available to providers, practitioners and/or members/participants upon request. Requests for criteria can be submitted via telephone, fax, electronically, or USPS. Once the request is received, care management associates send the requested criteria to the requestor via fax, electronically or USPS.

Network Health does not reward in any way practitioners or other individuals conducting utilization review for denying coverage for care or service. Nor does Network Health Plan prohibit providers from advocating on behalf of members within the utilization management program. Network Health does not use incentives to encourage barriers to care and service, and it does not make decisions about hiring, promoting or terminating practitioners or other associates based on the likelihood, or the perceived likelihood, that the practitioner or associate supports, or tends to support, denial of benefits. In addition, the medical director, associates (or designees), care management staff and supervisors of this staff receive no financial incentive to encourage decisions that result in underutilization.

Access to our Care Management or Utilization Management teams: call 920-720-1602 or 866-709-0019.

Callers have the option to leave a message 24 hours a day, seven days a week. Messages are retrieved at 8 a.m., Monday through Friday, as well as periodically during the business day. All calls are returned promptly. Calls received after business hours are returned the next business day. Members/Participants, practitioners and/or providers may also send inquiries to the care management department through secure email on the provider portal, fax, and USPS. You can fax the utilization or care management department at 920-720-1916.

Network Health offers TDD/TTY services for deaf, hard of hearing or speech-impaired individuals. Anyone needing these services should call 800-947-3529. Bilingual language assistance or translation services are also available. Callers may leave a message 24 hours a day, seven days a week.