Provider Resources

Authorization Information

Authorization Lists and Forms

Review authorization submission and response timelines, find listed services that require prior authorization for general medicine, pharmacy, genetic testing and experimental or investigational services. 

Medicare Plans
Commercial Plans

View Sample Member ID cards for help identifying patient plan types and benefits. 

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 with the ability to:

  • 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 authorizations from eviCore healthcare for advanced imaging, cardiac diagnostics and radiation oncology therapy services below. 

Non-Emergent Services

  • All ambulatory CT, MRI, MRA, PET scans
  • All ambulatory cardiac diagnostics including diagnostic cardiac catheterizations, nuclear cardiology scans, stress echocardiograms, transesophageal echocardiograms and transthoracic echocardiograms
  • Outpatient oncology radiation therapy
  • Spinal procedures
  • Joint procedures of the hip-knee-shoulder
  • Interventional pain procedures

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. 

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.

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

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 Inpatient Tutorial and Outpatient Tutorial.

Additional Information

For questions regarding authorization requests, please contact Network Health’s Utilization Management Department.
Medicare: 866-709-0019
Commercial: 800-236-0208 

 


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
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Tuesday: 8 a.m. to 4 p.m.