Policies Overview

On this page you will find many helpful documents, including Network Health Plan/Network Health Insurance Corporation's (NHP/NHIC) claims policies, as well as, many of the forms you will need to access as a NHP/NHIC provider. If you need a form or additional information that you don't see listed here, please contact us.

Important Note Regarding
ThedaCare Services & Facilities

Effective for HMO, Point-of-Service (POS) and Self Funded Plans for dates of service on or after August 1, 2010, there are new utilization management requirements for requests involving Theda Clark Regional Medical Center and Appleton Medical Center. All elective procedure service requests to be rendered by non-participating independent specialists will be re-directed to participating specialists at participating facilities per the non-participating authorization process (NHP/NHIC may approve such requests without redirecting if the service requested is not available at another in-network facility). NHP/NHIC's Medical Director will have authority for decisions that involve non-participating specialists.

Non-Participating Specialists:

• Children's Hospital of Wisconsin, Fox Valley and physicians
• Fox Valley Pulmonary Medicine, LLC
• Curtis Baltz, M.D.
• Radiation Oncology physicians of Appleton Radiology Associates (Radiation Oncologists on the campus of Appleton Medical Center)

All elective services requests by participating providers at Theda Clark Regional Medical Center (TCMC) involving anesthesia services will be re-directed to participating facilities with participating ancillary providers (i.e. anesthesia) per the non-participating authorization request process (Medical Director makes determination). All elective service requests involving non-participating anesthesia or independent specialists for POS members may be approved.  The POS member will be informed that those services rendered specifically by the non-participating provider will be at the out-of-network benefit.

Non-participating Anesthesiologists:

• Association of Hospital Anesthesiologists, S.C. (Anesthesiologists for Theda Clark Regional Medical Center). Service requests involving anesthesia include but are not limited to:
  • Surgical procedures
  • Obstetrics
  • Pain Clinic spinal procedures