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Provider Resources

April 2022

Table of Contents

Important Notice – Change Healthcare
eviCore Provider Portal Training Sessions
How Do Health Plans Make Decisions?
Provider Portal Reminder
Reminder – Consultation Code Policy
Vision Hardware Services Post Cataract Surgery
Orthopedic Footwear and Custom Molded Orthotics – Medicare Advantage
Reminder – eviCore Implant Audit Program
Reminder to Review the EDI Claims Rejections Report
EDI Claim Submissions – COB and Corrected Claims
Medical Record Requests for Risk Adjustment


Important Notice - Change Healthcare

Change Healthcare will update their network that supports Network Health's products and services. During this time, the following processes will experience interruptions or be unavailable.

• Ability to submit claims
• Ability to pick up reports and remittance
• Eligibility
• Claim status

These processes will be affected between 10 p.m. Friday, May 20 and 10 a.m. Saturday, May 21. If needed there will be a second phase implemented, from 10 p.m. Saturday May 21 and 10 a.m. Sunday, May 22.

eviCore Provider Portal Training Sessions

Provider training sessions are offered by eviCore Healthcare twice a week to help ensure smooth and timely prior authorization reviews for our provider partners. The eviCore provider portal training sessions focus on how to navigate the eviCore provider portals and what information is required to complete timely reviews. These sessions are free of charge and offered every Tuesday and Thursday.

Network Health encourages eviCore Portal Training for all new employees as well as any current employee needing refresher training. Here is a complete list of services requiring prior authorization review from eviCore Healthcare. Your employees can register for an eviCore provider portal training session by following these steps.

• Go to
• Select “WebEx Training” from the menu bar on the left.
• Click the "Upcoming" tab.
• Choose one of the eviCore training sessions.

  • eviCore Portal Training - Offered twice a week, this general training is focused on eviCore portal navigation and how to place authorization requests. Recommended for all new employees and those needing refresher training.
  • Provider Prior Authorization Online Portal Tips and Tools - Offered once a month, this provider forum provides helpful tips to avoid denials and provides guidance for eviCore resources.
  • Therapy Provider Portal Training - Offered once a month, this portal training is dedicated only for therapy programs and how to navigate placing authorizations for PT/OT/Chiropractic services.
• Click “Register” next to the session you wish to attend. Users should use the search bar at the top of the page and filter offerings by searching for one of the specific sessions outlined above.
• Enter your registrant information.

Registrants will receive an email containing a toll-free phone number, meeting number, conference password and a link to the web portion for the session they sign up for. Please keep this registration confirmation e-mail until the day of the session for easy log-in.

How Do Health Plans Make Decisions?

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. Criteria are available to providers, practitioners and/or members/participants upon request. Requests for criteria can be submitted via telephone, fax to the numbers listed below, 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 does not reward in any way practitioners or other individuals conducting utilization reviews for denying coverage for care or service. Nor does Network Health prohibit providers from advocating on behalf of members/participants within the utilization management program. Network Health does not use incentives to encourage barriers to care and service, and it does not make decisions about hiring, promoting or terminating practitioners or other associates based on the likelihood, or the perceived likelihood, that the practitioner or associate supports, or tends to support, denial of benefits. The medical directors, associates (or designees), utilization management employees and supervisors receive no financial incentive to encourage decisions that result in underutilization.

Network Health assures access to medical and behavioral health population health associates for our members and their practitioners and office staff seeking information about our care or utilization management programs. If you have questions about the care or utilization management program, please contact care management at 866-709-0019 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 5 p.m. In addition, treating practitioners may discuss medical necessity denial determinations with a Network Health medical director by contacting us at the number above.

Callers have the option to leave a message 24 hours a day, seven days a week. Messages are retrieved at 8 a.m., Monday–Friday, as well as periodically during the business day. All calls are returned promptly. Calls received after business hours are returned the next business day. Providers may also send inquiries to the utilization management department via fax, and USPS. You can fax the utilization management department at 920-720-1916.

Bilingual language assistance or translation services are also available.

Provider Portal Reminder

Due to continued staffing shortages, we are asking our providers to continue using our secure provider portal to verify member eligibility, member benefits, and claim status. By using the portal, it will avoid long hold times when contacting our member experience team. If you or your team are not currently registered for the provider portal, please click here to begin the process. If you have questions regarding the registration process, please reach out to your provider operations manager.

Reminder - Consultation Code Policy

Network Health does not reimburse for consultation codes for all lines of business. Please ensure claims are coded with the appropriate evaluation and management (E/M) code based on the complexity of the visit performed. If you have questions regarding the Consultation Code Policy, please reach out to your provider operations manager.

Vision Hardware Services Post Cataract Surgery

Network Health offers benefit plans that provide coverage for basic frames and lenses post cataract surgery. If a member is requesting additional enhancements, please submit the basic frame and lens charge for reimbursement and the enhancements separately, so we can deny the enhancement(s) as not covered and you may collect from the member.

Orthopedic Footwear and Custom Molded Orthotics - Medicare Advantage 

Are you aware of the requirements needed to be reimbursed for orthopedic footwear and custom molded orthotics? Network Health has noticed an increase in claims for orthopedic footwear and custom molded orthotics that do not meet Medicare guidelines and billing criteria for coverage. We want to alert you that we follow the Centers for Medicare & Medicaid Services (CMS) guidelines and criteria for professional claims submitted for orthopedic footwear or custom molded orthotics. Please click here to review the Medicare coverage guidelines. If you have questions regarding the coverage guidelines, please reach out to your provider operations manager.

Reminder - eviCore Implant Audit Program

Effective June 1, 2021, Network Health and eviCore began auditing implants submitted with Revenue codes 274-276 and 278 for all lines of business. The claim is reviewed by eviCore to ensure accurate billing of the implant, and they may request medical records via fax. If they do not have a fax number for the medical record request, a letter will be mailed to the address submitted on the claim form. You may not bill Network Health for the cost of the records.

If the medical records are not returned to eviCore within 90 days of the request, the charges will be recouped in full. If a billing discrepancy is identified, Network Health will recoup the cost associated with the implant, the recoupment may be partial or in it’s entirety. Providers have the option to appeal the determination through eviCore within 45 days of the decision.

If you have questions regarding the eviCore Implant Audit Program, please reach out to your provider operations manager.

Reminder to Review the EDI Claims Rejections Report 

As a reminder for all providers, you must review the EDI Claims Rejection Report located within the provider portal, to ensure claims did not reject due to clerical errors or a provider/member was not added to the system. Network Health does not reject the claims through the EDI process.

Your clearinghouse may indicate the claim was accepted however, the claim will not come back through your clearinghouse as rejected. It is very important to check this report if you have not received payment within 30 days.

If you have any questions on how to access this report, please reach out to your provider operations manager.

EDI Claim Submissions - COB and Corrected Claims

As a reminder, Network Health secondary claims along with corrected claims may be submitted electronically for claim processing. Please use the correct designation payer loop(s) when submitting claims as the secondary payer.

When submitting a corrected UB04/facility claim, please use bill type XX5, XX7 or XX8 indicating it is a correction to a previous claim submission. When submitting a HCFA-1500/professional claim, please indicate resubmission code 7 in box 22 along with the original claim number.

If you have additional questions, please review our Claim Submission Policy, or reach out to your provider operations manager.

Medical Record Requests for Risk Adjustment

As a Medicare Advantage plan, Network Health is required to submit member diagnosis and demographic information to the Centers for Medicare & Medicaid Services (CMS). Health plans like Network Health create internal risk adjustment programs to help monitor their member population, improve quality of care and increase the accuracy and completeness of these data submissions in order to achieve the most accurate payments from CMS for their member population. The risk adjustment model distributes payments to payers based on an expectation of what the member’s health care will cost. For example, a member with type 2 diabetes and high blood pressure merits a higher payment than a healthy patient, as their cost of health care will differ. By risk adjusting plan payments, CMS can make accurate payments to health plans for enrollees with different expected medical costs.

Our review of medical records is a compliance measure to ensure our data submissions and payments from CMS are based upon reliable and accurate records from physicians and facilities. These chart reviews aim both to highlight missing diagnoses and to locate diagnoses that were added in error. Both should be sent to CMS to adjust their payments to us. Our goal is to capture the full burden, no more, no less, of illness each year for our members. CMS has strict criteria concerning the medical record documentation used for risk score calculation. Only records signed by approved provider types for services performed in approved locations can be used for diagnosis validation. While any health care provider with a National Provider Identifier (NPI) may submit claims for payment of services, only face-to-face encounters with approved specialty types are acceptable for abstracting diagnosis codes for risk score calculation.

If a chronic condition is not recaptured from a previous year, the member’s risk score will decrease for the current year. Likewise, if additional conditions are reported, the member’s risk score will increase from what it was in the previous year. To maintain predictability in health care costs and revenue, Network Health relies on its risk adjustment program and the accurate and consistent submission of all conditions each year.

Providers have an important role to play in our risk adjustment program. An engaged partnership with Network Health is vital to bringing needed and valuable benefits to your patients. For instance, Network Health uses premiums and risk adjustment payments to offer our members enrollment in exercise programs, case or disease management, transportation to medical appointments, and other needed services. We use diagnosis codes submitted on claims to identify what types of programs are needed and who needs them.

Due to the volume of records we are reviewing, we use outside vendors to assist in the collection of records. You may be contacted by Inovalon or GeBBS Healthcare to submit specific records or have the vendor come on site to review the records. This review is not a medical necessity review. A letter outlining the program and a list requested records will be sent to you, along with several retrieval options to allow you to choose what works best for you and your staff.

We appreciate your partnership and cooperation. If you have any questions, please contact Emily Vander Heiden, supervisor risk adjustment at 920-628-7107 or

Network Health
1570 Midway Place
Menasha, WI 54952
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.