Legal

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.

If you are a Network Health member and have questions about the utilization process at Network Health, a utilization management decision, or would like a copy of specific utilization criteria you may call the care management department. Our associates are available Monday–Friday, 8 a.m. to 5 p.m., at 866-709-0019 (TTY 800-947-3529). Language assistance is available for members to discuss utilization management issues. Callers may leave a message 24 hours a day, seven days a week.


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.