How Do Health Plans Make Decisions

We were confident we could get her the care she

needed. - Hannah N.

experience, no matter how unique. Sheila is no exception. She’s been with Network Health for five years—the last two as a care manager— and has 20 years of experience in the medical field. Sheila’s done everything from pediatrics and hospice to high-risk pregnancies and long-term and acute rehabilitation.

“The people in the care management department are all experts. They know all the care you should be getting and how to access it,” Hannah said. “They understand not just the insurance side of things, but the care side too. They provide an extra opportunity to get more information and more support as you are going through scheduling appointments, understanding test results or finding new doctors. They’re just really good at what they do.”

Added Adam, “And don’t ever be afraid to ask questions. Ask a lot of questions. They’ll get you the answers.”

The Future Despite all the Neylons have been through in the last five years, they are not about to complain. They have embraced their journey and become stronger as a family. “We appreciate how happy and healthy our children are,” Adam said. “We feel very blessed. Our situation can be a challenge and can be a struggle at times. But if this is the worst it’s going to be for our kids, they have a very blessed and fulfilled life ahead of them.”

“These medical issues are just a part of our life,” added Hannah. “It’s not a tragedy that happened to us. It’s not something we are regretful of. It’s just something that’s a part of our life and part of our kids’ lives.”

“We talk a lot in our family about the special things you are born with. How people are born special instead of how they are born different.”

The Neylons look forward to what the coming years will bring. Like every parent, they can’t wait to watch their children grow and see who they become, because they know the possibilities are endless. For Hannah, Adam, Elizabeth, Tommy and Henry, the past only matters in how it has helped define their character and who they will be in the future.

How Do Health Plans Make Decisions?

Did you know that utilization decisions made about care by management staff and supervisors of this staff receive no financial Network Health are based on the appropriateness of care and incentive to encourage decisions that result in underutilization. service? Care and service include medical procedures, behavioral health procedures, pharmaceuticals and devices. Decisions are In addition, treating practitioners may discuss medical necessity based on written criteria founded on sound clinical evidence and the denial determinations with the physician review medical director by benefits outlined in the various coverage documents. The written contacting our utilization management team at 920-720-1600 or criteria are reviewed and approved annually by actively-participating 800-236-0208. For questions specific to behavioral health utilization, practitioners. Criteria are available to providers, practitioners and/ they can call 920-720-1340 or 800-555-3616. or members/participants upon request. Requests for criteria can be submitted via telephone, fax, electronically or USPS. Once the request Callers have the option to leave a message 24 hours a day, seven days is received, utilization management associates send the requested a week. Messages are retrieved at 8 a.m., Monday through Friday, criteria to the requestor via fax, electronically or USPS. as well as periodically during the business day. All calls are returned Network Health does not reward, in any way, practitioners or other business day. Members/participants, practitioners and/or providers individuals conducting utilization reviews for denying coverage for may also send inquiries to the care management department via care or service. Nor does Network Health prohibit providers from fax, courier system and USPS. You can fax the utilization or care advocating on behalf of members/participants within the utilization management department at 920-720-1916. management program. Network Health does not use incentives promptly. Calls received after business hours are returned the next to encourage barriers to care and service, and it does not make Network Health offers TDD/TTY services for deaf, hard of hearing or decisions about hiring, promoting or terminating practitioners or speech-impaired individuals. Anyone needing these services should other associates based on the likelihood, or the perceived likelihood, call 800-947-3529. Bilingual language assistance or translation that the practitioner or associate supports, or tends to support, denial services are also available. Callers may leave a message 24 hours a of benefits. The medical directors, associates (or designees), care day, seven days a week.