Authorization Information

Utilization Management (UM) Provider Survey

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.

Authorization Lists by Code

Network Health provides a downloadable Excel document of the Master Authorization list by code (CPT/HCPCs). *Please note, inpatient services require prior auth, 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, AsCommercial Membership (Fully Insured)sure, 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.

2023 Authorization Lists by Code (downloadable)
2022 Authorization Lists by Code (downloadable)

Authorization Lists and Information

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
Clinical Criteria for Utilization Decisions

Medicare Plans

2023 Medicare PPO/EGWP Prior Authorization List
2022 Medicare PPO Prior Authorization List
2022 Medicare HMO Prior Authorization List

Commercial Plans

2023 Prior Authorization Lists

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

2022 Prior Authorization Lists - Click here for 2022 information

Provider Documents

OP/DME Services Requests

• Sclerotherapy/Stab Phelbectomies (Commercial)
• Sclerotherapy/Stab Phelbectomies (Medicare)
• Varicose Veins Intervention (Commercial)
• Varicose Veins Intervention (Medicare)
• Skin Subsitiutes-Breast Reconstruction (Commercial and Medicare)
• Skin Substitutes-Non-Health Surgical, Traumatic and or Radiation Therapy Wounds (Commercial and Medicare)
• Blepharoplasty/Canthoplasty and Related Procedures (Commerical)
• Blepharoplasty/Ptosis Repair or Ectropion Repair (Medicare)

Inpatient Acute Services Request

• Inpatient Admission/Concurrent Review Checklist

Submitting Requests for Prior Authorization

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

eviCore healthcare

Request prior authorizations from eviCore healthcare the services below. 

Non-Emergent Services

• All ambulatory CT, MRI, MRA, PET scans (Commercial lines of business only)
• All ambulatory cardiac diagnostics including diagnostic cardiac catheterizations, nuclear cardiology scans, stress echocardiograms, transesophageal echocardiograms and transthoracic echocardiograms (Commercial lines of business only)
• Gastroenterology services including EGD, capsule endoscopy, diagnostic colonoscopy effective 7-1-2021
• Interventional pain procedures
• Joint procedures of the hip-knee-shoulder
• Medical oncology services
• Molecular genetic laboratory testing
• Outpatient oncology radiation therapy
• Part D oncology drugs effective 1-1-2022 (Medicare line of business only) 
• Spinal procedures (Commercial lines of business only)
• Therapy services including physical and occupational therapy effective 6-1-2021

Request Authorization

Register online for an account
Submit a request online 24 hours a day, seven days a week
Call 855-727-7444
Fax 888-693-3210
Monday - Friday, 7 a.m. to 8 p.m.

eviCore Resources

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.

Additional Information

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. 

ESI Care Continuum (CCUM)

Network Health has partnered with ESI Care Continuum (CCUM) for medical drug prior authorization effective May 1, 2019. CCUM will handle pre-determination and prior authorization requests for medical drug (excluding oncology drug) for all lines of business, including Medicare and Health Exchange. eviCore will continue to review oncology medical drug requests.

ESI Care Continuum Prior Authorization Drug List

June 2023
July 2023

Use the time-saving CCUM portal for faster medical drug prior authorization requests (excluding oncology drug). 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.

Learn more about ESI Care Continuum

Drug requests can be submitted via the ExpressPAth 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. 

iExchange

These are for authorizations submitted directly to Network Health, such as inpatient hospital stays, durable medical equipment, outpatient procedures and more.

Request Authorization

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

iExchange Resources 

For guidance, view our iExchange Tutorials.

Additional Information

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