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
Inpatient Hospital Care – Routine Supplies and Services
Inpatient Hospital Readmission
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 (Commercial)
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
Recoupment Request Form
Robotic Assisted Surgery
Self Administered Drugs (SAD) Policy/Medicare Advantage
Sequestration Policy
Special Investigation Unit
Special Rules for Inpatient Hospital Stay
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 

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
Autonomic Nervous System Testing
Balloon Sinuplasty
Benign Skin and Subcutaneous Lesions
Breast Implant Removal and/or Replacement
Chiropractic Services
Complimentary or Alternative Medicine
Drug Metabolite and Alcohol Testing Frequency
Endobronchial Valves for the Treatment of Severe Emphysema
Home Phototherapy Units for the Treatment of Skin Conditions
Hypoglossal Nerve Stimulation
Implantable Loop Recorder
In-Home Intensive Outpatient Psychotherapy
Medical Necessity Guidelines for Claims without Medical Records
Mobile Cardiac Telemetry (MCT)
Nerve Blocks and Ablation Therapy for Treatment of Knee Pain
Orthognathic Surgery
Peroral Endoscopic Myotomy (POEM)
Pneumatic Compression Devices
Post Vitrectomy Support Devices 
Reduction Mammaplasty
Skin Substitutes - Collagen Dermal Matrix Materials
Specialized Manual Wheelchairs
Transgender and Gender Dysphoria / Gender Incongruence Services
Tumor Treatment Field Therapy (TTF)
Varicose Vein Treatments 

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
Business Information Protection
Diverse Population-Cultural and Linguistic Needs
Privacy and Confidentiality of Member Information and Records
Network Management 
Practitioners Communication, Advice to Patients