Network Health 2024 Medicare Advantage PPO plans are rated 5 out of 5 stars by Medicare. Learn more.

Provider Resources

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 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.

2024 Authorization Lists by Code (downloadable)
2023 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
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

Medicare Plans

2024 Medicare PPO/EGWP Prior Authorization List
2023 Medicare PPO/EGWP Prior Authorization List

Commercial Plans

2024 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

2023 Prior Authorization Lists - Click here for 2023 information

Provider Documents

OP/DME Services Requests

Inpatient Acute Services Request

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
We have partnered with the following external vendors for authorization requests.

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 (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
  • Part D oncology drugs (Medicare line of business only) 
  • 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

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 2024
July 2024

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. 

ESI Care Continuum Registration Portal User Guide
Video Portal Tutorials
ExpressPAth Quick Start Guide

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


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.

COVID-19 Information for Network Health Members