Provider Resources

July 2019

Table of Contents

Claims Submitted with Incomplete Information Will Be Rejected
Pharmacy Transitions to ESI January 1, 2020
Medicare Survey Must Be Completed August 30
Medicare Plan Changes and Member Events
Updated Drug List Published for CCUM
Updates Posted to Claims and Medical Policies
Providers Must Update Data with Dial America

Incomplete Claims Will Be Rejected

Network Health’s goal is to process all claims at initial submission. Before we can process a claim, however, it must be a clean or complete claim submission.

If any of the necessary information is missing from the claim, we will not be able to process your claim in a timely fashion and it will be rejected.

To facilitate the timely processing of your claims, please follow the Claims Procedures and Polices provided.

If you are unable to find a claim on your remit report, please check the rejection report in the provider portal.

PBM Transitions to Express Scripts January 1, 2020
Walgreens added to Retail Pharmacy Network August 1

On January 1, 2020, Network Health will transition to Express Scripts (ESI) as the pharmacy benefits manager for all lines of business. ESI has provided pharmacy benefits management for Network Health Medicare members since 2005. Through the transition, the major retail pharmacy network will switch from CVS/caremark™ to Walgreens.

For our members’ convenience, Network Health will provide access to Walgreens pharmacies beginning August 1, 2019. CVS/caremark™ will continue to be in-network until December 31, 2019. This gives you and your patients time to transition pharmacy files from CVS/caremark™ to Walgreens (or any in-network pharmacy).

If members decide not to participate in the early transition, we have advised them to refill prescriptions the last week of December 2019 to cover their medication needs until they can transfer their pharmacy files to an in-network pharmacy on January 1, 2020.

Members and providers can search the entire updated pharmacy network, both retail and mail order, through the Find a Pharmacy tool at starting November 1, 2019.

Medicare Survey Must Be Completed by August 30

For Network Health to demonstrate compliance with the Centers for Medicare and Medicaid Services (CMS) requirements, providers must complete a short questionnaire by August 30.

You will receive an email invitation in August with a link to the survey. Please watch your inbox and complete your survey by the deadline.

CMS requires all providers contracted to offer health care or provide services to Network Health members to meet these requirements. If you have any questions regarding CMS requirements or this questionnaire, please contact your assigned contract manager.

Provider Communication Survey: Please Share Your Feedback

At Network Health our mission is to improve the life, health and wellness of the people we serve. Our relationship with providers plays a vital role in that mission, and we want to hear from you.

In September, we will email you a short survey about provider communications—how we share information with you and the types of information we share.

When you receive the email, please take a few minutes to complete our survey. Your feedback helps us understand what is working and where we have opportunities to improve. Thank you for your participation. We appreciate your ongoing partnership.

October: Medicare Plan Changes and Member Events

It’s that time of year again—we are in full swing preparing for the Medicare annual election period (AEP). We are busy finalizing plans and composing our annual notice of change (ANOC) to send to members by the end of September.

In October we will send provider offices an explanation of what benefits have been added and changed to help you prepare for January 2020.

We will also hold Medicare Member Events in October to announce the 2020 benefits.

Our provider partners are invited to participate in these events and promote their services to current and prospective members. If you are interested in setting up a booth at these events, please contact your contract manager.

Updated CCUM Drug List Published

Throughout the year, Network Health continually updates the list of medical drugs that require prior authorization through ESI Care Continuum (CCUM). Our updates maintain alignment with the evolving pharmaceutical marketplace. The most recent update has an effective date of October 1, 2019.

Previous changes to the drug list can be found below.
ESI Care Continuum Prior Authorization Drug List
October 1, 2019
July 21, 2019
July 1, 2019
May 1, 2019
April 29, 2019

Reminder: Updates Posted for Claims and Medical Policies

In June, we announced additions to claims and medical procedures and policies. Based on feedback from providers, we combined a few claims policies and created several new procedures to clarify processes. We also added two new medical policies. These changes took effect July 28, 2019.

The new claims policies are located under Claims Policies and Procedures and include the following procedures.

  • Correcting Provider Overpayments and Underpayments
  • Subrogation
  • Contract Pricing Updates
  • Bill Audit Review
  • Emergency Observation Inpatient Copayment

The medical policies are listed under Medial Policies at on the Policies and Forms page, and include the following policies.

  • Carotid Artery Stenting
  • Specialized Manual Wheelchairs

Providers Are Required to Update Data with Dial America

We validate provider information quarterly and when new information is sent from a contracted group. Contracted providers and provider groups are required to participate in this process as part of their contractual obligation.

Dial America is a vendor that Network Health uses to update provider information as regulated by CMS. Please make sure to update your information with them when they call. If you do not provide the information to Dial America, Network Health must follow up with your staff.

If you would rather not provide information over the phone, you have the option to submit your roster via email on a quarterly basis to Provider Informatics. If you would like to switch to email rosters, please contact your contract manager. For more information on what information is required, please read the Provider Data Validation policy.

Report changes in provider participation

It is also a contract requirement to promptly (within 30 days) inform Network Health of any provider participation changes such as location changes, terminations, part-time covering or no longer excepting new patients. Failure to report this information in a timely fashion affects the state and federal continuity of care provision for our members.


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