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Provider Resources

Policies

Network Health's policies are reviewed and updated annually. It is your responsibility to check this page often for new and/or revised policy changes.

Claims Policies and Procedures

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
Add On Codes
Ancillary
Anesthesia
Assistant Surgeon
Balance Billing Policy
Bilateral Procedures
Bill Audit Review
Canceled Claim-Billed in Error Policy
Claim Submission
Coding Policy
Consultation Code Policy (Professional Billing)
Contract Pricing and Coding Updates Policy
Co-Surgeon and Team Surgeon
Coordination of Benefits
Correcting Provider Overpayment or Underpayment
Discontinued Procedures
DME Service - Medicare Line of Business

Global Surgery
Home Ventilator Reimbursement
Hospital-Acquired Conditions
Increased Procedural Service Reimbursement
Infusion Alternative Site of Care - Commercial/ETF/SF
Inpatient Hospital Care – Routine Supplies and Services
Inpatient Hospital Readmission
Interim Rate Letter Reimbursement
Lesser Of Provider Reimbursement
Medicare A/B Rebill
Medicare Advantage Annual Wellness/Preventive Exam/E&M Exam
Medicare Default Pricing Policy
Mid-Level Practitioner/Physician Extender Policy
Modifier 52/Reduced Services Policy - Commercial
Multiple and Endoscopic Procedure Policy
Multiple Imaging Reduction on the Technical
Multiple Therapy Reduction
Never Events
Outpatient Implant Policy
Outstanding Overpayment
Partial Inpatient Authorization Policy
Physical Occupational Therapy Assistant
Postoperative Co-Management Care (Modifer 55)
Preventive Medicine (Commercial)
Provider Dispute Policy
Provider Dispute Procedure
Provider Meet and Greet Visits
Providers Treating Self and Family Members
Pulse Oximetry
Radiopharmaceutical Reimbursement Policy - Medicare
Recoupment Request Form
Robotic Assisted Surgery
Self Administered Drugs (SAD) Policy/Medicare Advantage
Sequestration Policy
Status Code Policy
Subrogation
Telehealth
Unbundling
Unplanned Return to Operating Room – Modifier 78
Wheelchair Rental Policy
Workers' Compensation Submission

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.

 

Credentialing Policies and Procedures

View policies and procedures related to credentialing, recredentialing and provider data maintenance for contracted providers.  

Medical Policies and Clinical Guidelines 

These medical policies provide guidance to the utilization management teams
at Network Health for considering and reviewing authorization requests for the
following treatment types:

Acupuncture
-  n03717 Policy Summary
Autonomic Nervous System Testing
-  n05706 Policy Summary
Balloon Sinuplasty
-  n05705 Policy Summary
Benign Skin and Subcutaneous Lesions
-  n00311 Policy Summary
Breast Implant Removal and/or Replacement
-  n00310 Policy Summary
Complementary or Alternative Medicine
-  n05697 Policy Summary
Drug Metabolite and Alcohol Testing Frequency
-  n05621 Policy Summary
Endobronchial Valves for the Treatment of Severe Emphysema
-  n05666 Policy Summary
Home Phototherapy Units for the Treatment of Skin Conditions
-  n05632 Policy Summary
Hypoglossal Nerve Stimulation
-  n05692 Policy Summary
Implantable Loop Recorder
In-Home Intensive Outpatient Psychotherapy
-  n05747 Policy Summary
Medical Necessity Guidelines for Claims without Medical Records
-  n05677 Policy Summary
Mobile Cardiac Telemetry (MCT)
-  n05532 Policy Summary
Nerve Blocks and Ablation Therapy for Treatment of Knee Pain
Orthognathic Surgery
-  n05630 Policy Summary
Peroral Endoscopic Myotomy (POEM)
-  n05742 Policy Summary
Pneumatic Compression Devices
-  n05719 Policy Summary
Post Vitrectomy Support Devices 
-  n05657 Policy Summary
Reduction Mammaplasty
-  n00229 Policy Summary
Skin Substitutes - Collagen Dermal Matrix Materials
-  n05819 Policy Summary
Specialized Manual Wheelchairs
-  n05652 Policy Summary
Tumor Treatment Field Therapy (TTF)
-  n05676 Policy Summary
Varicose Vein Treatments
-  n05654 Policy Summary

Network Health may use vendor guidelines to support utilization management activities of specific services, including physical and occupational therapy, joint and spine procedures, gastroenterology services, oncology services and advanced radiology services. In these situations, vendor guidelines may be used to support medical necessity and other coverage determinations.

MCG Clinical Guidelines: https://networkhealth.access.mcg.com/index

eviCore: https://www.evicore.com/resources/healthplan/network-health-wisconsin

General Policies and Forms

Prohibition of Health Screening Prior to Enrollment
Medicare Required Disclosure of Information to Beneficiary
Qualified Medicare Beneficiary Program Billing Requirements
No Member Discrimination in Delivery of Health Care
Notification of Continuity of Care for Termination of Specialty Care, Obstetric Care and Primary Care (Medicare is not included)
Published Review Criteria
-  n00240 Policy Summary
Business Information Protection
Diverse Population-Cultural and Linguistic Needs
Privacy and Confidentiality of Member Information and Records
Network Management
Practitioners Communication, Advice to Patients

Network Health Medical Policy Development and Application

Network Health’s medical policies list the criteria our clinicians use to decide when medical services are considered “reasonable and necessary” (also called “medically necessary”).

Centers for Medicare & Medicaid Services (CMS) require MA plans to provide the same medical benefits as original Medicare. MA plans must follow National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). They must also follow general coverage and benefit conditions in original Medicare laws. That includes using the same coverage criteria to decide if an item or service is covered by original Medicare.

There are times when a Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria. When that happens, CMS allows MA plans like Network Health to create and use our own internal coverage policies. We must base those policies on current evidence in widely used treatment guidelines or clinical literature. And they must be publicly accessible (listed above).
(42 CFR 422.101(6) (i)):
(i) Coverage criteria not fully established. Coverage criteria are not fully established when:

  1. Additional, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. The MA organization must demonstrate that the additional criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services;
  2. NCDs or LCDs include flexibility that explicitly allows for coverage in circumstances beyond the specific indications that are listed in an NCD or LCD; or
  3. There is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria.

We will only use an internal coverage policy for a customer’s specific condition when a Medicare policy, an NCD or LCD is not fully established. CMS policies are not fully established when any of the following apply :

  • More criteria are needed to interpret or support general provisions in an NCD, LCD or other Medicare coverage policy; or
  • There is flexibility allowed in an NCD or LCD; or
  • There is no applicable NCD or LCD to decide medical necessity; or
  • There is no applicable Local Coverage Article (used with an LCD) to decide medical necessity; or
  • A Medicare policy does not address the customer’s specific condition for the request under review; or
  • A Medicare policy does not include specific coverage criteria. A Medicare policy may have broad guidelines, but it may not have enough detail to decide if the request is medically necessary.

Additionally, we may use our own policies when a Medicare policy allows for more coverage than what is written in the Medicare policy. When our clinicians use internal clinical criteria, each customer’s unique clinical situation is considered with current CMS guidelines and our clinical policies, as applicable.


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.

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