800-826-0940 | 920-720-1300

Annual Provider Notification

Dear Contracted Practitioner and/or Provider,

Thank you for providing care and services to our members. To the right you will find information related to our Commercial Utilization and Case Management programs, including services requiring authorization, technology assessments, utilization management criteria, access to utilization management services and our policy on incentives.

The 2012 Services Requiring Authorization – Commercial list is available on the right side of this page. The following are revisions to the 2011 list and are effective on January 1, 2012:

  • Addition of the following services for all Commercial products including Self Funded:
    • Replacement of implantable cardioverter-defibrillator
    • Revision or removal of implantable spinal neurostimulator
    • Replacement of implantable pain pump
    • Total lumbar disc arthroplasty; revision including replacement of total lumbar disc arthroplasty; removal of total lumbar disc arthroplasty
  • Removal of Psychological and neuropsychological testing for all Commercial products including Self Funded
  • Removal PT/ST/OT authorization for Affinity Health System Self Funded membership only

Also, effective January 1, 2012, certain radiology imaging studies will be exempt from gold card status. National Imaging Associates will review the following imaging studies for clinical appropriateness prior to approval: CT Lumbar Spine, MRI Lumbar Spine, CT Virtual Colonoscopy, CT Screening Colonoscopy, MRI Heart, Coronary Artery Ca Score, CT Heart, CT Heart congenital studies, CTA Coronaries, MRI Breast, PET Scan Heart, Cerebral Perfusion Analysis CT, and Head/Brain CT.

Lastly, the OVA1 multiplex blood test has been added to the list of services requiring review under the experimental/investigational process.

Please access Network Health's authorization requirements, authorization request forms; potentially experimental, DME, genetic testing and imaging codes and services requiring prior authorization as well as other provider information on Network Health's Provider webpage.

If needed, please contact our Care Management Department with Commercial authorization requests or for hard copies of our authorization request forms and/or genetic testing, potentially experimental and DME codes requiring authorization at 800-236-0208 or 920-720-1600. For Behavioral Health Services call 800-555-3616 or 920-720-1340.


Sincerely,
 
Edward Scanlan M.D.
Medical Director
Network Health