Provider Resources

October 2019

Table of Contents

Reminder to Complete Our Annual Provider Satisfaction Survey
Network Health Outscores National Averages in Quality Ratings
Network Health Organizational Changes to Better Serve You
How Telehealth Can Be Part of the Solution
We Need Your Help – Watch for Upcoming Access to Care Survey
How to Get Faster Medical Drug Prior Authorizations
Medicare Part B Step Therapy
Submitting Urgent Online Prior Authorization Requests Through eviCore
Network Health’s Medication Therapy Management (MTM) Program
CPT and HCPCS Code Updates
Convenient Provider Portal Claims Functionality
Important Instructions for the Notice of Medicare Non-Coverage (Skilled Nursing Facility and Home Health Care Providers Only)
2020 Plan Changes (Medicare and Individual and Family Plans)

Reminder to Complete Our Annual Provider Satisfaction Survey

At Network Health, it’s essential to us that we continue to improve and enhance the service we provide to you. As a valued partner of Network Health, provider feedback is extremely important to us and we carefully review the results to implement improvements. In 2018, providers rated Network Health well above other plans and your feedback was key in helping us to focus on what’s most important.

For 2019, you should have received our annual Provider Satisfaction survey through SPH Analytics. The survey started at the beginning of October. Please complete the survey and provide your feedback. All surveys were emailed to the contract contact. If you have any questions or did not receive your survey, contact Melissa Anderson at

Network Health Outscores National Averages in Quality Ratings

Network Health earned a 4.5 out of 5 overall Star rating for its Medicare Advantage PPO plans from the Centers for Medicare & Medicaid Services (CMS), outperforming the national average of 4 Stars. Every year, Medicare evaluates plans based on a 5-star rating system. In addition, the National Committee for Quality Assurance (NCQA) awarded Network Health a 4.5 out of 5.0 rating for both Medicare and commercial lines of business for 2019-2020. Network Health is one of only four health plans in Wisconsin receiving this score for Medicare and commercial plans, and no other plans in Wisconsin are rated higher.

The Medicare Advantage Five-Star Quality Rating System was implemented to drive improvements in quality of care and to help consumers make plan comparisons. CMS evaluates plans annually and bases the Five-Star ratings results on clinical data, customer survey responses and plan performance scores spanning the previous two years. This information is timely as consumers start evaluating available health plans during open enrollment for 2020 insurance coverage.

“These ratings recognize the satisfaction of our Network Health members and the excellent care they receive from our providers,” said Kimberly Swanson, MPA, vice president, quality and clinical integration of Network Health. “Our primary goal is to take care of our members, because we live and work in the same communities.”

NCQA ratings are based on clinical quality, member satisfaction and NCQA Accreditation survey results. Ratings emphasize care outcomes and how members rate their care. Ratings are also given on a scale of zero to five, with five being the highest rating. Network Health is ranked in the top 38 commercial plans and top 25 Medicare plans of the more than 1,000 plans that are NCQA rated.

The health care industry is striving to make improvements in the delivery of high-quality care and the overall member and patient experience. Network Health has always partnered with local providers, including provider owners Ascension and Froedtert, to offer high-quality coverage. With this 4.5 Star rating, Network Health is currently the largest provider-owned Medicare Advantage plan in Wisconsin outranking the national average.

We thank all of our provider partners for their support and for the high-quality care you provide every day.

Network Health Organizational Changes to Better Serve You

At Network Health, we’ve recently made a few changes in our network development department to better serve our providers.

Cynthia Schmidt has been hired as Network Health’s Director of Managed Care Contracting to head up our contracting team with Dawn Malueg and Linda Jeanty. Under Cynthia’s leadership, Dawn and Linda will be accountable for negotiating contracts, annual contractual updates, provider/facility information updates, network adequacy and they’ll serve as liaisons between providers and credentialing.

Melissa Anderson, Network Health’s Director of Provider Operations, will head up our provider operations team with Jill Stoken, Liz Gillis and Natalie Knaack. Under Melissa’s leadership, Jill, Liz and Natalie will be accountable for provider orientation, provider education, payment policies, practice/specialty meetings and they’ll serve as liaisons between providers and claims, customer service, care management and payment integrity.

These changes will allow us more time to focus on the specific needs of our providers.

If you have any questions about the changes, feel free to contact Cynthia Schmidt at or Melissa Anderson at

How Telehealth Can Be Part of the Solution

Network Health partners with MDLIVE® to bring Network Heath members access to online doctor visits. These virtual visits, conducted by phone, smartphone, tablet or computer, are a convenient and affordable alternative to urgent care if a member’s personal doctor isn’t available or his or her office isn’t open. These visits do not replace the care of a member’s personal doctor, but they can help solve some of the most common problems facing physicians today.

  • Less calls after-hours, on evenings and weekends. MDLIVE has board-certifiedphysicians and pediatricians available 24 hours a day, seven days a week.
  • Nationwide access. If Network Health members are traveling, they have access totrusted providers from wherever they are through MDLIVE. And if they run out ofmedication, MDLIVE physicians can help with short-term prescription refills, untilmembers can get home to see their doctor.
  • Quality of care. MDLIVE’s friendly, board-certified providers are professionallytrained to use virtual technology to treat many non-emergency conditions. MDLIVEdoctors are board-certified and have an average of 15 years of experience. They’llalso fax visit details to the patient’s primary doctor to ensure continuity of care.
  • Reduced health care costs. MDLIVE’s virtual visits are a cost-effective alternative tourgent care or the emergency room. Most Network Health members pay $0 for anMDLIVE virtual visit and the total cost of care is less because there is no brick-and-mortar space required.
  • Positive patient experience. Network Health members have provided positivefeedback about using MDLIVE. They can see a doctor right away or schedule anappointment time that works for them, giving them piece of mind and quick accessto urgent care, if and when they need it.

We Need Your Help – Watch for Upcoming Access to Care Survey

As you know, Network Health reaches out to our provider partners on an annual basis for quality and other NCQA related activity. The information we receive helps support our quality scores and ratings.

In November, Network Health will be sending out a short, electronic survey asking three to five questions about access to care for our members visiting your offices. This short survey will replace outbound calls we’ve made in the past.

Please watch your email for this brief survey and complete it at your earliest convenience. The survey should take no more than five minutes to complete.

Thank you in advance for completing the survey. We sincerely appreciate your time and attention to ensure we have the most up-to-date information.

How to Get Faster Medical Drug Prior Authorizations 

Network Health has partnered with ESI Care Continuum (CCUM) for medical drug prior authorizations. CCUM handles pre-determination and prior authorization requests for medical drug (excluding oncology drug) for all lines of business, including Medicare and individual and family plans. eviCore will continue to review oncology medical drug requests.

The portal contains logic to save providers time by only requiring answers to the specific questions necessary to demonstrate medical necessity. This takes 5 to 10 minutes.

Please avoid using the faxed questionnaire, as there is not logic built in, so there are unnecessary questions in the fax document. If the portal isn't used, we recommend calling CCUM to provide the necessary information.

Submit drug requests in the CCUM ExpressPAth portal, available 24 hours a day, seven days a week, through seamless access in the Network Health provider portal.

Learn more about ESI Care Continuum on the Authorization Information page.

Medicare Part B Step Therapy

Beginning January 1, 2020, Network Health will implement step therapy for seven classes of Medicare Part B prescription drugs. This drug list is available at

Submitting Urgent Online Prior Authorization Requests Through eviCore

At Network Health, we’re continuously working to simplify the prior authorization process. In our efforts to enhance your online experience, initiation of urgent/expedited prior authorization requests online is now available on eviCore’s MedSolutions platform. Providers can request authorizations from eviCore for advanced imaging, cardiac diagnostics and radiation oncology therapy services.

By requesting urgent/emergent requests online you’ll …
  • have the opportunity to receive an automatic approval
  • avoid phone call(s)
  • check request status in real time
  • save time 

To learn how to request an urgent online prior authorization request, see this Instructions Sheet. If you haven’t yet created an account with eviCore, register online for an account today.

Network Health’s Medication Therapy Management (MTM) Program

As part of our Medication Therapy Management (MTM) program, Network Health is reviewing medication profiles for targeted Medicare Part D members. The official vendor to administer the MTM program on behalf of Network Health is SinfoníaRx, an industry leader in MTM services.

Medicare beneficiaries are automatically enrolled in the MTM program when they meet certain criteria.

  • Member must have at least three of the conditions below. o Osteoporosis
    • Chronic heart failure
    • Diabetes
    • Dyslipidemia
    • Hypertension
    • Asthma
    • COPD
    • Depression
  • Members must be on a minimum of seven covered Part D drugs for chronic/maintenance therapy
  • Members must have incurred one-fourth of the specified annual cost threshold in the previous quarter.

If SinfoníaRx is unable to perform an annual comprehensive medication review with the member directly, the Center for Medicare and Medicaid Services (CMS) allows for the completion of this review with the provider. Please be aware that SinfoníaRx may reach out to your office to conduct these reviews with your medical staff. This program is offered at no cost to the member.

For more information about this program, please see this SinfoníaRx flier or call the Network Health clinical pharmacist line at 888-665-1246.

CPT and HCPCS Code Updates

Quarterly, the American Medical Association updates Current Procedural Terminology (CPT) codes and the Centers for Medicare & 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 the Authorization Information page in the Provider Resources section of

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 Authorization Information page in the Provider Resources section of

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. 

Convenient Provider Portal Claims Functionality

In the Network Health provider portal, a new function is now live in the claims section to search for claims by service date range. This enhancement was the direct result of feedback submitted by providers through the Network Health feedback tool inside the portal. Thank you to those who submitted feedback and watch for more enhancements in the coming months.

As a reminder, providers can also log in to the Network Health provider portal to check any claims that may have rejected via the EDI process. If you can’t find a claim on your remit report, please check the EDI Claim/Error Log Report posted in the provider portal under Claims. If any of the necessary information is missing from a claim, it will be rejected.

Important Instructions for the Notice of Medicare Non-Coverage (Skilled Nursing Facility and Home Health Care Providers Only)

When Network Health Medicare Advantage members are discharged from a skilled nursing facility (SNF) or home health care (HHC) services, the Centers for Medicare & Medicaid Services (CMS) requires that the standard CMS Notice of Medicare Non-Coverage (NOMNC) form be sent by providers to members on a timely basis.

You can find the NOMNC in our online Medicare Provider Manual.

To be compliant with the Code of Federal Regulations, 42 CFR 422.624, members must receive the NOMNC from their provider no later than two days before the proposed end of services.

The NOMNC informs members that their SNF or HHC services are ending and of their right to appeal through LiVanta, an independent quality improvement organization that is contracted with and paid by CMS.

The completed notice must include the following.

  • Services to end
  • The date coverage ends (dates must be no smaller than 12-point type, and if handwritten, notice entries must be no smaller than 12-point type and legible)
  • The date the member received notification
  • The member’s unique identification number
  • The member’s signature

To access CMS’ instructions on how to properly fill out a NOMNC form, visit the CMS website.


2020 Plan Changes

New $25 Insulin Program for Commercial Members

Beginning January 1, 2020, Network Health is introducing the Patient Assurance Program which provides less expensive insulin options for our commercial members—including those who get insurance through their employer and those who purchase on their own.*

The Patient Assurance Program lists insulin as a preventive drug, which brings preferred brand (tier 3) insulin copayments down to $25 for a 30-day supply or $75 for a 3-month supply. This allows all commercial members—even those on HSA-qualified plans—to access this $25 insulin benefit before they meet their deductible.

To determine which drugs fit into this program, you can view and search our drug lists on the Look Up Medications page of our website.

*Not available for Medicare plans and transitional, grandmothered or grandfathered commercial plans.

Medicare and Individual and Family Plan Highlights

2020 Network Health Medicare Advantage plan documents are now available on the Plan Materials page of A few highlights include the following.

  • To ensure all of our Medicare Advantage members have ID cards early this year, members received their 2020 ID card in October.
  • Enhancements to our Medicare plans include the following.
    • No drug deductible on Tier 1-3 medications (most plans with drug coverage)
    • A caregiver benefit has been added to all plans, offering support and local resources for members who are caring for other loved ones and for members’ authorized representatives
    • An over-the-counter drug benefit of $50 per quarter has been added to some plans
    • Wellness rewards are being added for our NetworkPrime (MSA) members to encourage them to have their annual wellness visit, routine labs and get a flu shot.

2020 individual and family plan information is now available on the Individual and Family Available Plans page of Our 2020 plans are being offered at reduced rates and feature the following.

  • $0 preventive care services
  • $0 annual vision exam through EyeMed
  • $0 routine dental exam, cleaning and x-ray through Argus Dental
  • $0 virtual doctor visits (for some plans, deductible must be met first)
  • A Momentum healthy rewards program, where members can earn a $100 gift card for completing four tasks essential to their health and wellness.

The individual and family plan enrollment period runs from November 1 – December 15.

The Medicare Annual Enrollment period runs from October 15 – December 7.

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