Claims Policies and Procedures

Network Health’s goal is to process all claims at initial submission. Before we can process a claim, it must be a clean or complete claim submission. If any of the necessary information is missing from the claim, we will not be able to process your claim in a timely fashion.

To facilitate the timely processing of your claim(s), please follow the Claims Policies and Procedures  provided below. 
All Claims Policies and Procedures apply to participating and non-participating providers.

Mail claims to: Network Health, P.O. Box 568, Menasha, WI 54952

Acupuncture Procedure - Commercial (HMO/POS)
Add On Codes
After Hours Evaluation and Management (1202)
Age Gender to Diagnosis Code (1203)
Ancillary (1204)
Anesthesia (1205)
Assistant Surgeon (1206)
Bilateral Procedures (1207)
Bill Audit Review (05695)
Cancelled Claim-Billed in Error Policy
CCI Editing
Claim Submission 
Consultation Code Policy (Professional Billing) (n05693)
Contract Pricing Updates Procedure
Co-Surgeon and Team Surgeon (1237)
Coordination of Benefits (1211)
Correcting Provider Overpayment or Underpayment 
Discontinued Procedures
DME Service - Medicare Line of Business
Emergency Observation Inpatient Copayment Procedure
Global Surgery
Hospital-Acquired Conditions (1238)
Increased Procedural Service Reimbursement (1215)
Inpatient Hospital Readmission (1602)
Lesser Of Participating Provider Reimbursement (1235)
Medicare A/B Rebill (n05670) 
Medicare Advantage Annual Wellness/Preventive Exam/E&M Exam (n05700)

Medicare Carrier Discretion Pricing (05686)
Mid-Level Practitioner/Physician Extender Policy
Multiple and Endoscopic Procedure Policy (Commercial)
Multiple Imaging Reduction on the Technical (1218)
Never Events (1239)
Outstanding Overpayment (1219)
Pulse Oximetry (1222)
Postoperative Co-Management Care (Modifer 55)
Preventive Medicine (1220)
Provider Dispute Policy (05678)
Provider Dispute Procedure
Provider Meet and Greet Visits (1221)
Providers Treating Self and Family Members (1234)
Recoupment Request Form
Reduced Services Reimbursement (1216)
Robotic Assisted Surgery (1224)
Sequestration Policy (n05673)
Special Investigation Unit (1236)
Special Rules for Inpatient Hospital Stay (05690)
Subrogation
Supply Codes (1227)
Team Conferences (1228)
Telehealth (05667)
Transfer of Inactive Provider Records Reimbursement (1233)
Unbundling (1208)
Workers' Compensation Submission (1231)

Network Health Claims Policies and Procedures are intended as a general reference/resource and are not intended to address every aspect of a reimbursement situation. Network Health uses reasonable discretion interpreting and applying these procedures to services being delivered. The claims policies/procedures are not intended to cover all topics and issues related to reimbursement for services rendered to Network Health members/participants.

The Claims Policies and Procedures are property of Network Health and unauthorized copying, use and distribution are strictly prohibited. Network Health reserves the right to terminate, change, suspend or discontinue any claims policies/procedures at anytime without notice. Changes in the claims policies/ procedures will be made effective when posted on this site. The claims policies/procedures are provided on an “as is” and “as available” basis without warranties of any kind, either express or implied.