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Policies and Forms
Network Health's policies are reviewed and updated annually. It is your responsibility to check this page often for new and/or revised policy changes.
General Policies and Forms
No Member Discrimination in Delivery of Health Care
Notification of Continuity of Care for Termination of Specialty Care, Obstetric Care and Primary Care (Medicare is not included)
Published Review Criteria
Business Information Protection
Diverse Population-Cultural and Linguistic Needs
Privacy and Confidentiality of Member Information and Records
Provider Information Form for Contracting
Facility Information Form for Contracting
Claims Policies and Procedures
To facilitate the timely processing of your claims, please follow the
claims polices and procedures provided.
Mail claims to: Network Health, P.O. Box 568, Menasha, WI 54952
Medicare Policies and Forms
We have collected information related to our Medicare processes, policies and procedures into one reference page called the Provider Medicare Manual.
Authorization Lists and Forms
Review authorization submission and response timelines, find listed services that require prior authorization for general medicine, pharmacy, genetic testing and experimental or investigational services.
Medicare Plans
Commercial Plans
Medical Policies
These medical policies provide guidance to the utilization management teams
at Network Health for considering and reviewing authorization requests for the
following treatment types:
Acupuncture
Autonomic Nervous System Testing
Balloon Sinuplasty
Benign Skin and Subcutaneous Lesions
Breast Implant Removal and/or Replacement
Chiropractic Services
Complimentary or Alternative Medicine
Drug Metabolite and Alcohol Testing Frequency
Endobronchial Valves for the Treatment of Severe Emphysema
Home Phototherapy Units for the Treatment of Skin Conditions
Hypoglossal Nerve Stimulation
Implantable Loop Recorder
Medical Necessity Guidelines for Claims without Medical Records
Mobile Cardiac Telemetry (MCT)
Nerve Blocks and Ablation Therapy for Treatment of Knee Pain
Orthognathic Surgery
Physical and Occupational Therapy Services
Pneumatic Compression Devices
Post Vitrectomy Support Devices
Reduction Mammaplasty
Skin Substitutes - Collagen Dermal Matrix Materials
Specialized Manual Wheelchairs
Transgender and Gender Dysphoria / Gender Incongruence Services
Tumor Treatment Field Therapy (TTF)
Varicose Vein Treatments
Clinical Guidelines
Network Health adopts and follows clinical practice guidelines to improve the quality of care for our members by assisting physicians and practitioners with a framework for specific illnesses.
Preventive Services Guide
In addition to an annual wellness visit, Network Health covers other preventive services at no cost for most of our members when they visit doctors within our provider network. Network Health follows the recommendations of the United States Preventive Services Task Force (USPSTF).
Commercial Preventive Services Guide
Appeals and Grievances Policies and Forms
For more information on the grievance process as well as member rights and responsibilities, please visit our legal page.
Commercial Grievance FormMedicare Appeal Request Form
Grievance and Appeals Resolution Policy and Procedure
for Medicare Advantage Plans Part D
Grievance and Appeals Resolution Policy and Procedure
for Medicare Advantage Plans Part C
Non-Contract Provider Claim Appeals (Medicare)
Waiver of Liability Form
Member Appeals Document
Reopening and Peer to Peer (P2P) Process Document
Credentialing Policies and Procedures
View policies and procedures related to credentialing, recredentialing and provider data maintenance for contracted providers.
