A different kind of health insurance company

Pulse Provider Newsletter

In this space, we will post articles from the most recent issue of our provider newsletter, The Pulse. Please watch your email quarterly for each issue. 

Have You Noticed Something Different about Our Website?

We recently launched our redesigned website, networkhealth.com. The redesign aims to make navigation easier for potential customers, current members, employers, agents and providers.

For providers, our homepage offers a quick sign in to our provider portal. The homepage also features a link to the Providers section—a centralized location for all the information and tools you frequently use. Here, you can find the latest Network Health news and announcements, including archived issues of The Pulse.

Click Policies and Authorizations on the right side of the Providers section and this will produce a drop-down list that includes authorizations, policies, our formulary and clinical practice guidelines.

Below the Policies and Authorizations tab, there's a Tools and Resources link that will open a drop-down list of forms, the iCES claims tool, manuals, appeals and our contact information.

We hope you find our redesigned website to be more user-friendly than in the past. One of our goals in redesigning the website was to give you quicker and easier access to everything you need.

Improving Coordination of Care

Did you know Network Health offers members case management services? This collaborative process provides a helpful resource for your patients with serious or poorly managed illnesses such as cancer, multiple traumas, diabetes, cardiovascular disease, COPD or any end-stage medical condition.

Our case management staff can help with any the following.

  • Coordinating services
  • Assisting with access to care
  • Reducing barriers to care
  • Monitoring conditions
  • Providing patient and family/caregiver education

Our case management services help members and providers navigate the health care system to get necessary services in an optimal setting. In addition, we aim to improve health care delivery and condition management, plus promote quality, cost-effective outcomes.

To learn more about Network Health’s case management services, call 920-720-1600 for commercial members and 920-720-1602 for Medicare Advantage members.

Members and providers can request help with a health condition using the same form.

Change to Behavioral Health Authorization for Commercial Members

Effective August 1, 2013, Network Health will be using the MCG (formerly known as Miliman Care Guidelines) behavioral health utilization models for behavioral health requests. This will include initial and concurrent requests for all levels of care, but does not apply to medication management or ECT services.

These guidelines provide population-based utilization rates for health services. The MCG guidelines for the 15 diagnostic groups are based on actual delivery of care statistics, and should closely resemble your practice.

Our request forms will be modified to align with MCG guidelines. If you have any questions or concerns, please contact us at 920-720-1340.

Falls Prevention Tool Kit 

According to the Centers for Disease Control and Prevention (CDC), one out of three people age 65 and older fall each year. Annually, over 2 million are treated for fall-related injuries in emergency rooms. Because falls are a serious threat to the health of your older patients, the CDC has created a helpful tool kit for providers to encourage fall prevention.

You can help your patients avoid painful and unnecessary injuries related to falls with the STEADI tool kit. The key features include:

Additional information about STEADI is available at the CDC website.

Falls prevention services can qualify for Medicare reimbursement and/or Physician Quality Reporting Initiative (PQRI) payment. The services must be medically necessary and billed appropriately to be considered for payment. Learn more about PQRI payment here.

If you have any questions or would like more information about falls prevention resources, please contact Barbara Peters at 920-720-1654 or bpeters@networkhealth.com.

Rewards Program Improves Diabetes Management

Network Health’s Diabetes Rewards Program was introduced to commercial members in 2010. Three years later, participation continues to increase. Based on data from January of 2013, of 4,045 eligible individuals, Network Health rewarded gift cards to 1,194 participants.

The number of participants meeting four or five key measures has increased from 23 percent in 2010 to 36 percent in 2013.
This month, we’ll be sending participants an update of their most current results. Those not meeting the criteria or needing updated results will be encouraged to contact their primary care physician. Members may present a lab form to you to get additional and/or updated lab information.

We’re glad to invest in our members’ ability to effectively manage their diabetes and hope you encourage your patients to take advantage of this program. We can provide a list of those eligible and our most current lab information. We can also provide a list of those not obtaining annual screenings related to diabetes. Thank you for accurately reporting and documenting labs in the correct areas of the medical record to assist with this process.

How does Diabetes Rewards work?
Network Health commercial members can earn up to $200 in annual rewards by getting the recommended annual tests or screenings and meeting the five key measures below.

  • A1C less than seven
  • LDL-C cholesterol less than 100
  • Blood pressure of 130/80 or lower
  • Kidney screening
  • Dilated-retinal eye exam

Rewards are paid twice a year. Members meeting four of five measures receive a $50 gift card. Those meeting all five receive a $100 gift card.

Members can also receive a one-time $50 reward for completing one of these self-management workshops

To learn more about Network Health’s Diabetes Rewards Program, call 800-769-3186 ext.01658.

If a patient that is not meeting the measures described above, you can refer him or her for case management services. To learn more about these services, please call 920-720-1602.

When Immunizations are Covered Under Part B vs. Part D

To ensure correct reimbursement, it’s important to know some vaccines are covered for Network Health Medicare Advantage members under their Part B plan and others under Part D. Below are some examples of which vaccines are covered under which program.

Immunizations Covered Under Part B
Providers bill the vaccine and its administration directly to the member’s Medicare Advantage plan, and the member has no copayments.

  • Pneumonia vaccine
  • Influenza vaccine (once a year)
  • Hepatitis B vaccine (if at high or intermediate risk)
  • Other vaccines if the member is at risk and meets Medicare Part B coverage rules

Vaccines not available for reimbursement under Part B (or Part A) will generally be covered under Part D when reasonable and necessary to prevent illness.

Immunizations Covered Under Part D (when criteria are met)
Providers should charge members for the vaccine and its administration, and may need to work with members and their Medicare Advantage plan to facilitate reimbursement.*  

  • Herpes zoster
  • Hepatitis B vaccine (when not high or intermediate risk)
  • Tetanus
  • Tdap
  • Hep A
  • MMR

* For the member to file for reimbursement up to the plan’s allowable charge, he or she will need the following information.

  • National Drug Code (NDC) of the drug
  • Quantity
  • An Express Scripts, Inc. (ESI) form. This will facilitate processing the reimbursement, although a CMS 1500 will work, too.
  • Proof of payment with a detailed receipt showing BOTH components (the vaccine and the administration charges).

For more information on covered drugs and vaccines for Network Health Medicare Advantage members, search our formulary online.

Use of Spirometry Testing to Diagnose COPD

Chronic Obstructive Pulmonary Disease (COPD) continues to remain a major public health concern nationally and locally. It’s now the third leading cause of death in the United States.

You can help ensure your patients receive the highest level of care by increasing the use of spriometry testing to diagnose COPD.

According to the GOLD guidelines, “a clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production and a history of exposure to risk factors for the disease.” Spirometry testing is required to diagnose COPD in the above clinical context.

Earlier diagnosis and treatment of COPD can improve quality of life and help members control their COPD. Below are Network Health’s current scores on the use of spirometry testing in the assessment and diagnosis of COPD.

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

National 90th Percentile. . . . . . 52.70
National Average . . . . . . . . . . . 41.72    
Wisconsin Average. . . . . . . . . . 40.69
Network Health. . . . . . . . . . . . 43.80  (50-75th percentile band)

To learn more about the GOLD COPD clinical practice guideline, visit www.goldcopd.org. If you have any questions about Network Health’s scores, contact Jan Cobia at jcobia@networkhealth.com or 920-720-1651 or 800-826-0940 ext. 01651.

Attention Oxygen and Durable Medical Equipment Providers

Beginning September 1, 2013, the Certificate of Medical Necessity (CMN) for oxygen rentals will need to be submitted with prior authorization requests for Network Health Medicare Advantage members RATHER than being submitted with the claim. This process change is being made to help ensure timely and accurate claims processing.

Please note all prior authorization requests for durable medical equipment, including oxygen, need to be submitted to Network Health’s Utilization Management Department within seven calendar days of the first date of service or equipment being provided.

The Importance of Cholesterol Screening and Management

According to the Centers for Disease Control and Prevention, people with high cholesterol have twice the risk of heart disease as people with optimal levels. But, less than half of adults with high LDL cholesterol get treatment.

More than one out of every three Network Health members who are at high risk for a heart attack and/or stroke (identified as having a diagnosis of ischemic vascular disease, diabetes or a cardiac event such as AMI, CABG or PCI) do not have LDL levels within the recommended range of <100mg/dL.

As you know, the risks of heart disease can be prevented or treated. Please talk with your patients about the importance of cholesterol screening and management. Network Health covers annual preventive serum cholesterol screenings for all adults, and offers a variety of comprehensive drug benefit plans to our members.

Network Health follows the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel in the Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATP III) for clinical guidance on the management of dyslipidemia. While the next update is being developed, current recommendations include LDL thresholds at which to begin both Therapeutic Lifestyle Changes (TLC) and drug therapy based on risk stratification. Typically, that’s >100mg/dL and >130mg/dL, respectively, for high-risk patients.

For a list of covered drugs, use the links below.

Network Health 2013 Preferred Drug List (Commercial)
Network Health 2013 Formulary (Medicare Advantage)

If you have questions or would like more information about this topic, contact Denise Balboa, RN, at dbalboa@networkhealth.com or 920-720-1695.

Clinical Practice and Preventive Guideline Updates

Network Health requires clinical practice guideline reviews a minimum of every two years, or sooner when revisions occur. The review process which included contracted practitioners has been completed, and Network Health’s Quality Management Committee (QMC) approved continued adoption of the following guidelines.

  1. The Institute for Clinical Systems Improvement (ICSI) continues to be the adopted guideline source for several clinical practice guidelines and has released revisions for the following. Adult Acute and Sub-acute Low Back Pain - Fifteenth edition
  2. The Wisconsin Diabetes Advisory Group released its 2012 Wisconsin Diabetes Essential Care Guideline. The group originally developed the guideline in 1998, when Network Health reviewed and approved its adoption. Wisconsin Diabetes Mellitus Essential Care Guidelines 2012
  3. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) revised the guideline for COPD – February 2013.

For more information, visit the Provider section of our website. You’ll find specific policies, authorizations and clinical practice guidelines. If you'd prefer a hard copy of the guidelines, call Network

Health’s Quality Improvement Department at 920-720-1229 or 800-826-0940 ext. 1229.

To learn more about preventive guidelines, reference the U.S. Preventive Services Task Force’s (USPSTF) recommendations.

Practitioner Access and Medical Record Standards

Practitioner appointment access and medical record standards are required to ensure Network Health members receive timely, high-quality health care. These standards are monitored by the National Committee for Quality Assurance.

Network Health’s Access Committee regularly measures and reports practitioner access to its executive committee.

It’s also required that practitioners have medical record keeping practices and standards that comply with regulatory requirements regarding confidentiality, availability, organization, documentation standards and performance goals.

You can access these standards on our website in the Provider section under Policies. If you prefer a hard copy of the policy, please call Network Health’s Quality Improvement Department at 920-720-1229 at 800-826-0940 ext. 1229.

Pharmacy Updates

New Prescription Drug Monitoring Program

The Wisconsin Department of Safety and Professional Services launched a new tool on their website for providers and pharmacists. This helpful resource allows health care professionals to search a database for information about patients or potential patients.

The site provides data on all federal and state controlled substances in Schedule II, III, IV or V (and Tramadol) dispensed in a Wisconsin pharmacy to a Wisconsin resident.

For step-by-step instructions on how to register and access the Prescription Drug Monitoring Program data, visit http://dsps.wi.gov/pdmp/access.

Three Tips for Making Drug Prior Authorizations Easier

  1. Remember to check if the member has commercial or Medicare Advantage prescription drug coverage. Some Medicare members have Network Health for medical coverage, but a different insurer for drug coverage, like SeniorCare.
  2. Have all prescription history available to better answer questions. Many denials are a result of not having prescription history initially. Including the history right way, instead of waiting until completing the appeal, will help avoid delays.
  3. Check if prior authorization is required on a Step Therapy medication. Sometimes, the member may have been non-compliant and the medication may have been filled outside the look-back window. Ask the member about prescription compliance and if cost is creating a problem.

CAREMARK Prior Authorization for Commercial Members


  • 855-839-5206 (Phone)

  • 888-836-0730 (Fax)

Express Scripts Prior Authorization for Medicare Advantage Members


800-889-0376 (Phone)

Timing Requirements for Authorization Requests

In an effort to give providers more information regarding our authorization processes, we’ve developed timeframes for submitting authorization requests.

View timeframes for submitting an authorization request

Providers will receive written notification of approved and/or denied authorization requests, including an authorization identification number when approved. The authorization ID number is needed for payment of associated claims for services that require authorization (please ensure you have an authorization ID number on file prior to submitting the claim).

All authorization requests must be submitted to Network Health’s utilization staff by fax or phone.

  • For Medicare, 920-720-1916 (fax) or 920-720-1602 (phone)

For commercial, 920-720-1903 (fax) or 920-720-1600 (phone).

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.

For the third quarter, the following codes were added that require authorization.

  • Codes that will be evaluated under our experimental/investigational review process:
    • G0460-Autologous Platelet-Rich Plasma for chronic wounds/ulcers, including phlebectomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
  • DME codes:
    • K0008-Customized manual wheelchair/base
    • K0013-Custom motorized power wheelchair/base
    • A9274-Disposable drug delivery system including elastomeric infusion pump
  • Implantable cardioverter-defibrillator codes:
    • C1721-Cardioverter-defibrillator, dual chamber (implantable)

Please forward this information to those within your facility who will need to follow these processes. These services and correlating codes did not previously require authorization, but they'll require authorization for services provided on or after September 1, 2013.

Please make note of the following changes.

  • Implantable cardioverter-defibrillator insertion or replacement, including components, require authorization. These codes include 33230, 33231, 33249, 33232, 33263, 33264 and C1721.  
  • As of September 1, 2013, noninvasive prenatal testing for aneuploidy will no longer require prior authorization, unless the service is completed by a non-participating provider.
  • The 2013 List of Services Requiring Authorization has been updated.

More information about authorization requirements, forms and codes that require review under the experimental and/or genetic process is located on the Provider Authorizations page of our website .

For commercial prior authorization requests or questions, contact our care management department at 800-236-0208 or 920-720-1600. For behavioral health services, call 800-555-3616 or 920-720-1340