Please take a few moments to fill out this short survey. The more feedback you can provide, the better relationship we can build with you.
Network Health provides a downloadable Excel document of the Master Authorization list by code (CPT/HCPCs). *Please note, inpatient services require prior authorization, but may not have a corresponding CPT or HCPC's code. The list contains links to the EviCore and CCUM authorization lists, please ensure you verify those lists independently for additional requirements. The lists are separated by line of business; Medicare PPO, Assure Commercial Membership (Fully Insured), State of Wisconsin (ETF), Commercial (Group), Individual and Family (IFP), Exchange (HIX), Horizon Home Care and Hospice, and Network Health. Please confirm the member's benefit plan before verifying the authorization requirements.
2025 Authorization Lists by Code (downloadable)
2024 Authorization Lists by Code (downloadable)
2023 Authorization Lists by Code (downloadable)
Review authorization submission and response timelines, find listed services that require prior authorization for general medicine, pharmacy, genetic testing and experimental or investigational services.
Participating Provider Timelines for Submitting Authorization Requests
iExchange and EviCore Healthcare Authorization Requests
Services Requiring Authorization
Care Management Staff Accessibility to Members and Practitioners
Did you know that utilization decisions made about care by Network Health are based on the appropriateness of care and service? Care and service include medical services and procedures, behavioral health services and procedures, pharmaceuticals and devices. Decisions are based on written criteria founded on sound clinical evidence and on the benefits outlined in our member coverage documents. The written criteria are reviewed and approved annually by actively practicing practitioners. Network Health licenses the use of MCG criteria, in addition to internally developed medical policies. MCG criteria are available to providers, practitioners and/or members/participants here, https://networkhealth.access.mcg.com/index, or upon request. Requests for criteria can be submitted via telephone (866-709-0019) or fax (920-720-1916), via electronic messaging through the provider portal or USPS to our office location. Once the request is received, utilization management associates will send the requested criteria to the requestor via fax, electronically or USPS. Network Health’s internally developed medical policies are publicly available here, https://networkhealth.com/provider-resources/policies-and-forms.
Clinical Criteria for Utilization Decisions
Medical Policy Development
Experimental and Investigative Procedures
2025 Medicare PPO/EGWP Prior Authorization List
2024 Medicare PPO/EGWP Prior Authorization List
2023 Medicare PPO/EGWP Prior Authorization List
Commercial Membership (Fully Insured)
Individual and Family Plans and Small Group ACA
Health Insurance Exchange
State of Wisconsin (ETF)
Self-Insured Assure Plans
Self-Insured Froedtert Health Plan
Self-Insured Horizon and Network Health
Commercial Membership (Fully Insured)
Individual and Family Plans and Small Group ACA
Health Insurance Exchange
State of Wisconsin (ETF)
Self-Insured Assure Plans
Self-Insured Horizon and Network Health
2023 Prior Authorization Lists - Click here for 2023 information
We are continually making improvements to our prior authorization processes.
Online submissions for authorizations streamline communication and improve turnaround times for requests. In addition, day-to-day operations in provider offices are improved these abilities.
Access authorization platforms 24 hours a day, seven days a week
Attach clinical notes and other documentation to requests
Confirm submissions, track requests and view status updates
We have partnered with the following external vendors for authorization requests.
EviCore Healthcare iExchange ESI Care Continuum (CCUM)
Please note - Network Medical Drug Management (MDM) authorization services will be submitted on EviCore.com.
Prior authorization request submissions for non-oncology specialty drugs for Network Health members will be submitted on EviCore.com.
Beginning January 1, 2025, prior authorization will be required for all ambulatory CT, MRI, MRA, PET scans for the Medicare lines of business.
Click here for an informational how-to document about EviCore
All ambulatory CT, MRI, MRA, PET scans (Commercial lines of business only) (Medicare lines of business beginning January 1, 2025)
All ambulatory cardiac diagnostics including diagnostic cardiac catheterizations, nuclear cardiology scans, stress echocardiograms (Commercial lines of business only)
Gastroenterology services including EGD, capsule endoscopy, diagnostic colonoscopy
Interventional pain procedures
Joint procedures of the hip-knee-shoulder
Medical oncology services
Molecular genetic laboratory testing
Outpatient oncology radiation therapy
Oncology drug reviews for all lines of business
Peripheral Vascular Disease (PVD) services
Carotid Disease: carotid endarterectomy, carotid stent and TCAR
EVAR/TEVAR
Venous Disease
Lower extremity endovascular procedures
Spinal procedures
Therapy services including physical and occupational therapy
Review the clinical guidelines for medical necessity.
Find CPT codes, FAQs, quick reference guides and other resources.
Link to EviCore's Required Medical Information Check List.
Peer-to-peer reviews are encouraged. All peer-to-peer discussions must occur at a physician-to-physician level. View peer-to-peer and reopen process flow diagrams.
Please note: While EviCore Healthcare may authorize a surgical procedure, inpatient stays related to any of the above services will require separate authorization from Network Health. For any required inpatient stay, please submit a request via the iExchange SSO in the provider portal.
Login via Network Health Provider Portal
Network Medical Drug Management (MDM) authorization services will be submitted on EviCore.com.
Prior authorization request submissions for non-oncology specialty drugs for Network Health members will be submitted on EviCore.com.
Click here for an informational how-to document about the OnePA MDM Migration for Network Health.
Use the time-saving EviCore.com portal for faster medical drug prior authorization requests. The portal contains logic to save providers time by only requiring answers to the specific questions necessary to demonstrate medical necessity. This takes 5 to 10 minutes.
Please avoid using the faxed questionnaire, as there is not logic built in, so there are unnecessary questions in the fax document. If the portal isn't used, we recommend calling CCUM to provide the necessary information.
Drug requests can be submitted via the EviCore portal, available 24 hours a day, seven days a week. Providers have seamless access to ExpressPAth through the Network Health provider portal. Providers should use their NPI number, not the facility NPI when submitting requests.
Network Health Wisconsin Provider Resources | EviCore by Evernorth
These are for authorizations submitted directly to Network Health, such as inpatient hospital stays, durable medical equipment, outpatient procedures and more.
If you are currently using iExchange with other payers, you will see Network Health in your payer drop-down menu. If you are new to iExchange, you may access the system via single-sign-on through our provider portal or by registering directly with iExchange (please use IE or Firefox browsers only).
iExchange is available 24 hours a day, seven days a week, and provides real-time entry into Network Health’s Care Management Platform. Users of iExchange experience the following benefits.
Confirmation of requests with tracking numbers
Ability to provide clinical notes to Network Health
Attach documents or provide additional information in the comments section
Ability to print an authorization request confirmation for your patient and your files
Alerts from Network Health when a request has been reviewed and updated
Ability to check the status of requests and avoid duplicate requests
For guidance, view our iExchange Tutorials.
Click here for the Population Health Authorization Request Form.
For questions regarding authorization requests, please contact Network Health’s Utilization Management Department at 866-709-0019.
Criteria are available to providers/practitioners and/or members/participants upon request. Requests for criteria can be submitted via telephone, fax or electronic messaging through the provider portal. Once the request is received, utilization management associates will send the requested criteria to the requestor via fax, electronically or USPS.
Phone: 866-709-0019
Fax: 920-720-1916