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Provider Resources

October 2020

Table of Contents

Provider Satisfaction Survey Reminder
Network Health Achieves 4.5 Star Rating for 2021
Network Health Referral Program 
2021 Annual Pharmacy Notification 
Provider Data Validation Using NPPES NPI Provider Data
CPT and HCPCS Code Updates 
Medicare Special Needs Program Reminder
FSP Program
Commercial Member ID Cards 


Provider Satisfaction Survey Reminder

Our 2020 annual provider satisfaction survey was sent out via email by SPH earlier this month. If you did not receive it, please check your junk mail or spam mail folder. If you cannot find it or haven’t had a chance to respond, SPH will be contacting you to conduct the survey via telephone.

Provider Satisfaction scores are used to improve our performance and they are incorporated into Network’s overall annual corporate goals. The survey takes less than five minutes and we would appreciate if you could spare the time to take it.

Network Health Achieves 4.5 Star Rating for 2021 

Network Health Medicare Advantage plans once again earned recognition as one of the nation’s top Medicare health plans, based on annual rankings recently released by the Centers for Medicare and Medicaid Services (CMS).Our team put forth a collaborative effort in achieving a 4.5 overall star rating for 2021.
Network Health earned the following ratings.

  • 5 stars for the Medicare Part D prescription drug rating
  • 3.5 Stars in our MSA plan
  • Specific areas scoring 5 stars for more than three years include the following.
    • Members getting appointments and care quickly
    • Health plan complaints
    • Multiple medication adherence measures

What is the Five-Star Rating?

The Five-Star Quality Rating System from CMS was implemented to drive improvements in quality of care and to help consumers make plan comparisons. CMS evaluates plans annually and base the Five-Star rating on a score of one to five, with five being the highest. Scores span the last two years and the results are based on the types of services offered by a health plan, including preventive medicine and chronic condition management as well as member experience and customer service.

This information is important to consumers as they start evaluating available health plans during open enrollment for 2021 insurance coverage. The Medicare annual enrollment period runs October 15, 2020 through December 7, 2020.

Thank you
This would not have been possible without the hard work of all our provider owners.Thank you for being a valued Network Health partner in helping us achieve this auspicious goal.
Network Health

Network Health Referral Program 

Our provider network is a significant advantage for which many Medicare shoppers choose Network Health Medicare Advantage every year. As our membership base grows, so do our providers.

Network Health is rolling out a member referral program that rewards our existing plan members for referring new members to Network Health. To be eligible, those referred must live in the Network Health service area, have Medicare Part A and Part B and not be on a Network Health Medicare Advantage plan.

Network Health Medicare Advantage members will receive a $15 gift card for every referral, with a maximum of $60 from four referrals to be paid in a calendar year. To refer, all an existing Network Health Medicare Advantage member must do is have somebody who meets the qualifications above call 8440-850-5284 and let them know who referred them.

2021 Annual Pharmacy Notification Program

Important pharmacy information, references and current contact lists are available for providers at

Formulary Overview

You will find our online formularies via the Look Up Medications tool. If you would like a printed copy of
the formularies, you may print the PDF documents directly from the website, or you can contact our
pharmacy department to have a copy mailed to you.

Network Health manages commercial, individual and family and Medicare formularies. All are very
similar with slight differences found within tier structures, drug tier placements, utilization management
rules and other requirements or restrictions.

Some of our utilization management strategies include prior authorizations, step therapy protocols,
quantity level limits and specialty drug restrictions. For commercial, individual and family and Medicare,
these rules are created and reviewed independently through our pharmacy and therapeutics committee
and are administered through our pharmacy benefits manager, Express Scripts, Inc. (ESI).

ESI administers prescription benefits for our commercial, individual and family and Medicare members,
including the review of our utilization management rules and maintaining the pharmacy network. ESI is
the designated contact for all clinical medication reviews, exceptions and authorizations, regardless of
the drug or pharmacy. In addition, ESI offers mail order services for all commercial, individual and
family, Medicare and most self-insured plan members. Mail order for Network Health self-insured
participants is handled through Ascension WI Retail Pharmacy Wausau.

Provider Data Validation Using NPPES NPI Provider Data 

Network Health is asking providers to begin updating their NPPES provider data to help maintain the accuracy of their provider directories. NPPES allows providers to attest to the accuracy of their NPI data.

If a provider’s information is correct, they will be able to attest to it and NPPES will record and reflect the attestation date. If the provider’s information is not correct when they request any change to the NPI record, the provider will be able to attest to their changed NPI data, resulting in an updated certification date.

CMS will publish the latest certification date for each NPI in the NPI Registry as well as the NPPES dissemination file. Network Health will be using this data to aid us in the development of our provider directories, however, we can only use the most current data published, therefore, it would be imperative that you attest to the data regularly.

NPPES was recently updated to input multiple addresses to support other work locations.

Network Health will access core NPPES data weekly i.e., provider name, provider specialty, provider address, provider telephone number. Collectively, these data elements represent 91% of the CMS provider directory review errors found. NPPES data will be compared to your provider data which is already being submitted and serve as an important resource to improve Network Health’s provider directory reliability and accuracy. 

We encourage you to access the NPPES webpage at today as well as quarterly to update and/or attest to your provider data. It will be imperative to ensuring provider directory accuracy to our members.

CPT and HCPCS Code Updates 

Quarterly, the American Medical Association updates Current Procedural Terminology (CPT) codes and the Centers for Medicare and Medicaid Services updates Healthcare Common Procedure Coding System (HCPCS) codes.
There are new codes that will require prior authorization and these services fall within our current authorization, experimental and/or genetic review processes. You can find a list of all services requiring prior authorization on line at

If you have specific questions regarding a service, please contact our customer service or health management teams for assistance. For more information about authorization requirements, forms or services that require review under the experimental and/or genetic process visit the Provider Authorizations section of our website at
We encourage you to access the NPPES webpage at today as well as quarterly to update and/or attest to your provider data. It will be imperative to ensuring p
Please forward this information to those within your facility who will need to follow these processes. For prior authorization requests or questions, contact our care management departments Monday through Friday; 8 a.m. to 5 p.m.

Commercial: call 920- 720-1600 or 800-236-0208. For questions specific to behavioral health utilization, call 920-720-1340 or 800-555-3616.

Medicare: call 920-720-1602 or 866-709-0019

Language assistance is available for members or practitioners to discuss utilization management issues. Network Health also offers TDD/TTY services for deaf, hard of hearing or speech-impaired individuals. Anyone needing these services should call 800-947-3529. All callers may leave a message 24 hours a day, seven days a week.

Medicare Special Needs Program Reminder

Federal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost-sharing under any circumstances (see Sections 1902(n)(3)(B),1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act [the Act]).

The QMB program provides Medicaid coverage of Medicare Part A and Part B premiums and cost sharing to low income Medicare beneficiaries. QMB is an eligibility category under the Medicare Savings Programs.

Providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. However, as permitted by Federal law, States can limit Medicare cost-sharing payments, under certain circumstances. Regardless, persons enrolled in the QMB program have no legal liability to pay

Medicare providers for Medicare Part A or Part B cost-sharing. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions (see Sections 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Act).

FSP Program 

We are growing our Family Savings Plan (FSP) business, so you may be seeing more of your patients
presenting the cards below. These individuals must present their health insurance card (which is not
Network Health) and then present the FSP card which his below. You will bill the health insurance
company. Then submit the EOB from the health insurance company and the claim to FSP. The FSP
plan reimburses you directly for the patient cost share. By following this process, you will not have to
collect from the member, you will simply receive a check from FSP within 30 days or less. FSP is not
secondary insurance, it only pays for copayments, coinsurance, and deductibles.


Commercial Member ID Cards  

If a member is staying on the same plan from last year, Network Health will not be updating the
member’s effective date on the card.

An example is, a member was effective with their group on January 1, 2020 and remains on that plan, their ID card will reflect an
effective date of January 1, 2020 not January 1, 2021. You may also check eligibility on our provider
portal at

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Current and archived issues of The Pulse, The Script and The Consult are available at

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