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Provider Resources

June 2021

Table of Contents

Reminder for Providers
Network Health Expanding Prior Authorization Programs with eviCore Healthcare
Virtual Practice Manager Meetings July 13 and 14
Supplemental Benefits
New Payment Policies
Population Health Services for Members
Reminder to Complete the Annual Provider Attestation
Statin Use in Persons with Diabetes Updated ICD-10 Esclusions
Provider Data Validation Using NPPES NPI Provider Data
Provider Data Validation

Reminder for Providers

  • Due to COVID, CMS allowed certain services to have cost share waived by appending a CS modifier to the claim line. There is a specific set of codes in which the CS modifier is allowed. If claims are submitted with the CS modifier and the CS modifier is not appropriate for the code, we will deny the claim. For more information on services that require a CS modifier, please visit:
  •  All provider disputes must be submitted through the provider portal. If we receive paper disputes, they will not be addressed and mailed back.


Network Health Expanding Prior Authorization Programs with eviCore Healthcare

The new prior authorization programs being implemented include chiropractic services, physical & occupational therapy services (PT/OT) and gastroenterology services.

  • Also beginning May 24, 2021, eviCore will begin accepting prior authorization requests for specialty therapy (PT/OT) for Medicare and Commercial members for dates of service beginning on or after June 1, 2021.
  • Beginning June 29, 2021, eviCore will begin accepting prior authorization requests for gastroenterology services (EGD, capsule endoscopy, colonoscopy) for Medicare and Commercial members for dates of service beginning on or after July 1, 2021.

eviCore’s Clinical Guidelines, CPT code lists, Frequently Asked Questions and request forms are available click here. Please keep in mind, services performed without authorization may not be reimbursed and you may not seek reimbursement from members.

The following orientation session has been designed to assist you and your staff with the new utilization management programs. This session will discuss the prior authorization requirements for therapy, chiropractic and gastroenterology services and how to navigate the eviCore portal. We encourage you to attend this session to ensure your understanding of the requirements and to promote your successful navigation of the eviCore authorization portal. The online orientation session is free of charge and will last approximately one hour. All sessions are scheduled in Central Time.  

Network Health Provider Orientation Training for Gastroenterology Services

July 1st



How to Register:

All online orientation sessions require advance registration.

  1. Once you have selected a provider specific session, please go to
  2. Click on the menu bar on the far left hand side, then choose “Webex Training”
  3. Under Live Sessions, click the “Upcoming” tab, then enter the desired topic name exactly as below and search: Network Health Provider Orientation Training for Specialty Therapy or Network Health Provider Orientation Training for Chiropractic Services or Network Health Provider Orientation Training for Gastroenterology Services.
  4. Click “Register” next to the session(s) with the date and time you wish to attend
  5. Complete the registration information

An e-mail is sent to confirm registration. Please keep the registration e-mail as it will contain the toll-free phone number, meeting number, conference password, and a link to the web training session you have registered to attend.

If you have any questions regarding the eviCore web portal, please contact the Web Support team via email at or via phone at 800.646.0418 (Option 2). For any Client or Provider inquiries not associated with this training, please email

Virtual Practice Manager Meetings July 13 and 14

It is that time of year again for the practice manager meetings. This time around we will be conducting two meetings, one hour in length via Zoom. Please feel free to forward this invite to others within your organization, the more the merrier! Here is the agenda of topics we will be discussing:

  1. Network Health Updates – Melissa Anderson
  2. UM Prior Authorization Updates – Sarah Dencker
  3. Pharmacy Prior Authorization Updates – Ted Regalia
  4. Family Savings Plan – Anne Roeder
  5. Provider Directory Update – Jennifer Delebreau
  6. Quality Health Integration and Member Experience – Nancy Weber

We understand that this is a busy time for you, so please make sure you look at the agenda and see if it pertains to your practice. However, we always welcome your participation.

We hope you are able to join us!

Please sign up for one of the following meeting times:

July 13 meeting:
You are invited to a Zoom meeting.
When: July 13, 2021 12:00 PM Central Time (US and Canada)

Register in advance for this meeting:

After registering, you will receive a confirmation email containing information about joining the meeting.

July 14 meeting:
You are invited to a Zoom meeting.
When: July 14, 2021 12:00 PM Central Time (US and Canada)

Register in advance for this meeting:

After registering, you will receive a confirmation email containing information about joining the meeting.

Supplemental Benefits

Do any of your patients who are NH Medicare Advantage PPO SNP, NetworkCares, members need a ride to their annual wellness or other doctor appointments? We can help.

Members of Network Health’s PPO SNP Medicare Advantage Plan have expanded benefits which includes non-emergent transportation at no cost to medical or health related destinations within the Network Health service area.

In addition, all of our NH Medicare Advantage PPO and HMO plans offer the transportation benefit to members who have ESRD and require hemodialysis.  They can receive up to 24 one rides each year to and from dialysis centers.

To set up transportation, your patient can call Aryv at 855-923-1113 (TTY 711) or visit the Aryv website at

Recovering after a hospital and skilled nursing facility stay can be difficult. Network Health's Medicare Advantage PPO SNP, NetworkCares, members may receive 28 meals after discharge from an inpatient or observation hospitalization or skilled nursing facility stay to home.  The meals are delivered right to the member’s home, after a qualifying hospital or skilled nursing facility stay.

To take advantage of this benefit, contact the Network Health Care Management Department at 866-709-0019 (TTY 800-947-3529), Monday-Friday from 8 a.m. to 5 p.m.

NH will need to confirm discharge within seven days of the discharge date to approve the meals.

Palliative Care Consult at Home
Your patients who have any of our Medicare Advantage PPO or HMO plans and have an end stage cancer diagnosis have access to a palliative care consult and evaluation in their home. We partner with home health and hospice agencies who provide the service in the member’s home.  If you would like to refer a patient, please contact us at 866-709-0019 and ask for a care manager. 

New Payment Policies

Effective August 1, 2021 Network Health will have 2 new payment policies for all lines of business:

  • Network Health will be reimbursing Physician Assistants (PAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNS) at 85% of the allowable unless otherwise specified in your contract. 
  • ​Network Health will reimburse 25% of the allowable amount when services are discontinued and modifiers 53 or 73 are appended to the claim. ​

These policies will be posted shortly to our website.  Please note, we develop policies on a regular basis, we will announce those policies in The Pulse, and we will post them to our website. Please ensure your staff is up to date with our policies.

Population Health Services for Members

Network Health plan members have access to a variety of programs to help them stay well and manage health conditions. These programs are available at no additional cost to members.

  • Wellness
    Network Health’s member wellness programs, including a prediabetes program, offer one-on-one health coaching, group support and individual learning resources to help members achieve and maintain a healthy lifestyle.
  • Condition Management
    Condition management is available to members living with asthma, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, stroke or heart failure. Our registered nurses engage members in one-on-one health coaching about their ongoing care, provides educational resources and helps build connections to community programs.
  • Care Management
    Care management is available for members with more complex medical or behavioral health needs and conditions such as cancer, end stage renal disease, organ transplant, and traumatic injuries. Whether they are dealing with a short-term illness or a more complex condition, personalized nurse or social work care managers assist members with developing goals, coordinating  community resources, navigating the health care system, medication review, and addressing barriers to getting the care they need.

To learn more about each program please log onto our provider webpage at

If you are caring for a Network Health member who may benefit from one of our programs you can refer them to us.

  • By phone at Network Health at 1-866-709-0019 (TTY 1-800-947-3529) Monday-Friday from 8 a.m. to 5 p.m.
  • Online at the Network Health provider resource page, click request help with a Health Condition –
  • Care and condition managers and health coaches are also available after regular business hours by appointment


Reminder to Complete the Annual Provider Attestation

Please remember to complete Network Health’s annual Provider Attestation on or before Saturday, July 31, 2021. This is a requirement per The Centers for Medicare and Medicaid (CMS) for all participating providers who offer health care or administrative services to Network Health members enrolled in a federal health care program.

The attestation is available through our Provider Portal, along with a Frequently Asked Questions (FAQ) document to assist with any questions. If you are not a registered user on our provider portal, please visit our website to create an account. If you have questions regarding the portal registration, please contact our Member Experience team at 800-769-3186. 

Statin Use in Persons with Diabetes Updated ICD-10 Exclusions

Effective 1/1/2021, there are updated ICD-10 exclusions for the Medicare quality measure of statin use in persons with diabetes (SUPD). Previous exclusions only encompassed hospice enrollment and end stage renal disease (ESRD). The updated exclusions now include rhabdomyolysis and myopathy, liver disease, pre-diabetes, pregnancy, lactation and fertility, and/or polycystic ovary syndrome. If a patient cannot tolerate a statin, this needs to be documented, coded and billed on the medical claim. Please note that only the following ICD-10 codes related to rhabdomyolysis and myopathy are included as an exclusion:



Drug-induced myopathy


Other specified myopathies


Myopathy, unspecified


Other myositis, unspecified site


Myositis, unspecified site




Adverse effect of antihyperlipidemic and anti-arteriosclerotic drugs, initial encounter



Additionally, our Statin Myth brochure can be a great starting point for opening the lines of communication between you and your patient. You can find a link to the electronic version here or request printed copies for your office by reaching out to the Network Health clinical pharmacist through email at or phone at 920-720-1287.


Provider Data Validation Using NPPES NPI Provider Data

Network Health is asking providers to begin updating their NPPES provider data to help maintain the accuracy of their provider directories.

NPPES allows providers to attest to the accuracy of their NPI data. If a provider’s information is correct, they will be able to attest to it and NPPES will record and reflect the attestation date. If the provider’s information is not correct when they request any change to the NPI record, the provider will be able to attest to their changed NPI data, resulting in an updated certification date.

CMS will publish the latest certification date for each NPI in the NPI Registry as well as the NPPES dissemination file. Network Health will be using this data to aid us in the development of our provider directories, however, we can only use the most current data published, therefore, it would be imperative that you attest to the data regularly.  NPPES was recently updated to allow providers to input multiple addresses to support other work locations. 

Network Health will access core NPPES data weekly i.e., provider name, provider specialty, provider address, provider telephone number.  Collectively, these data elements represent 91% of the CMS provider directory review errors found. NPPES data will be compared to your provider data which is already being submitted and serve as an important resource to improve Network Health’s provider directory reliability and accuracy.

We encourage you to access the NPPES webpage at today as well as quarterly to update and/or attest to your provider data.  It will be imperative to ensuring provider directory accuracy to our members.

Provider Data Validation 

Network Health’s Provider Informatics Department is now required by CMS and NCQA to obtain quarterly updates on provider and/or facility data. In the past, you may have worked with an external company on behalf of Network Health.

As of February 15, 2021, Network Health has brought this process in-house. Due to this, someone from our Provider Informatics Department will be reaching out to your group quarterly to obtain information to confirm that the information we have is accurate.

 If you are not a current subscriber to The Pulse and you would like to be added to the mailing list, please email us today.

Current and archived issues of The Pulse, The Script and The Consult
are available at

Network Health
1570 Midway Place
Menasha, WI 54952
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Tuesday: 8 a.m. to 4 p.m.