Concierge Fall 2019 for northeast and southeast Medicare members

L I F E , H E A LT H & W E L L N E S S

A PUBLICATION OF

FA L L 2 01 9

Preventive Care— A He Says, She Says Story Dennis and Cathy Ellisen, from Appleton, explain why routine preventive care is the key to living your best life.

Exclusive Reduced Rates for Network Health Medicare Advantage Plan Members For ticket information, visit networkhealth.com/offers Fox Cities Performing Arts Center Appleton, Wisconsin

Marcus Performing Arts Center Milwaukee, Wisconsin

EMISUNSHINE WITH SPECIAL GUEST ETTA MAY November 3 at 6:30 p.m.

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Tickets on sale now. Offer expires November 2, 2019.

THE PHANTOM OF THE OPERA December 15 at 6:30 p.m.

Tickets on sale now. Offer expires November 17, 2019.

All tickets subject to availability.

C

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Tickets on sale now.

Offer expires October 30, 2019.

THE LION KING February 6 at 2 p.m.

Tickets on sale now.

Offer expires January 15, 2020.

3 Letter from the President and CEO 4 The Five Seasons of Wisconsin

14 Lifecycle of a Claim

4 Benefits of an Annual Health Risk Assessment

15 Breaking Down Barriers to Care

5 Avoiding Medicare Fraud 5 Premium Payment Address Change 6 Stay Active to Improve Balance and Prevent Falls

10

15 Join All of Us 16 The Service You Deserve 18 What Happens When We Focus on Quality 18 Know Your Member Rights and Responsibilities

7 Did You Know ...

18 Access to Network Health Care Management Associates and Services

8 Dispensing Knowledge

19 Evaluating New Technologies

9 New Quality Improvement Organization

19 A Special Delivery, Just for You

FEATURE BACK COVER 10 Preventive Care—A He Says, She Says Story Get Social (For Real)

EDITORIAL STAFF President and CEO Coreen Dicus-Johnson Chief Administrative Officer Penny Ransom Strategic Marketing and Romi Norton Communications Manager Visual Design Lead Debra Sutton

ASK NETWORK HEALTH If you have questions about anything you read in this issue of Concierge, call customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, 8 a.m. to 8 p.m. You can also learn more at networkhealth.com.

Concierge is a biannual publication of Network Health. The health information contained in Concierge is meant to supplement, not replace, the advice of health care professionals. © 2019 Network Health Insurance Corporation. No portion of this newsletter may be reproduced without written permission from Network Health Insurance Corporation.

Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234 (TTY 800-947-3529). Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-378-5234 (TTY 800-947-3529). Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-378-5234 (TTY 800-947-3529). Y0108_1550-02-0919_C 2 | C oncierge

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life. health. wellness.

Letter from the President and CEO Hello and welcome to the fall edition of Concierge.

Thank you for being a Network Health Medicare Advantage member. I appreciate the trust you place in our organization.

Fall brings cool, crisp air, beautiful fall colors and change. The season of change allows us to share the benefit enhancements we will offer in 2020. We work closely with our provider-owners Froedtert Health and Ministry Health Care, part of Ascension Wisconsin, to create plans designed with you in mind. This unique approach—local providers working with a local health insurance organization—allows us to provide the best health insurance experience possible.

As a local health plan, we have the opportunity to meet members and to receive their valuable feedback while out in the community. I consistently receive praise and compliments about the great work of our health care concierge team and our care managers. Network Health provides exceptional service knowing we serve our neighbors, family and friends.

We look forward to serving you in 2020 and beyond.

Best regards,

Coreen Dicus-Johnson President and Chief Executive Officer

networkhealth.com

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life. health. wellness.

The Five Seasons of Wisconsin

By Tara Dontje, quality health integration coordinator for Network Health

A

lthough each flu season is unique and influenza affects people in different ways, millions of people get the flu every year. Influenza is a potentially serious and contagious respiratory illness that can lead to hospitalization and even death. You can protect yourself and your family by getting an influenza vaccine, also called the flu shot, which is the first and most important step to fight this illness. The Centers for Disease Control and Prevention (CDC) states its especially important that everyone 65 years and older get a flu shot every year. The flu shot can reduce the chance of getting the illness, and reduce doctor visits and missed work—leaving you more time to enjoy family and friends.

Be proactive this flu season and fight the flu—get your flu shot.

Benefits of an Annual Health Risk Assessment

By Mallory Mueller, quality health integration manager for Network Health

N

etwork Health offers a complimentary annual health risk assessment (HRA) to all members. An annual HRA gives you a yearly snapshot of your general health and well-being, preventive health risks, known medical conditions and can uncover potential gaps in care.

The benefits of completing an HRA don’t end after you receive your results. In fact, for many Network Health members, it’s just the beginning. We use HRA information to determine which members may benefit from additional assistance, including one-on-one support from a health coach or a nurse. Our team provides personalized over-the-phone coaching and care coordination to thousands of members each year.

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The levels of support range from guiding members with a newly emerging health risk—such as obesity, high cholesterol or prediabetes—to helping members with chronic concerns like diabetes, COPD, or cancer.

We want you to make the most of your insurance benefits; your physical and mental health are important to us. We are here to listen, provide support and give direction. At Network Health, we look forward to helping you feel your best.

Complete your HRA in your online member portal at login.networkhealth.com or to learn more, call 866-709-0019 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 5 p.m.

networkhealth.com

Avoiding Medicare Fraud M

edicare fraud costs American taxpayers billions of dollars each year and results in higher medical costs for everyone. Follow this guide to help keep your personal information safe.

DO

• Protect your Medicare card by keeping it in a safe place and treating it like a credit card.

• Read your Explanation of Benefits carefully and make sure all services listed are services you received.

• Use a calendar to keep track of your health care appointments.

• Ask questions about your medical care and understand how services are billed.

• Watch your credit card and bank statements for any improper billing or fraudulent activity.

• Monitor your credit report regularly.

• Report suspected instances of fraud.

DON’T

• Don’t accept any medical supplies you didn’t order.

• Don’t give your Social Security number, Medicare number, financial information, Network Health member ID number or credit card information to someone you don’t know.

• Don’t sign blank insurance forms.

• Don’t accept money or gifts for free medical care.

What if I’m scammed?

Sometimes people do not report scams because they are ashamed or embarrassed. It is important to know it’s not your fault. If you feel you are the victim of a Medicare scam, we are here to assist you. Call a member of our health care concierge team or send an email to paymentintegrity@networkhealth.com.

You can always call our Values Line to report and discuss activities or occurrences you believe are improper. The hotline is confidential, and you may report concerns anonymously. Your concerns will be investigated and appropriate action will be taken to address the problem.

The Values Line number is 800-707-2198 (TTY 800-947-3529) and can be reached 24 hours a day, seven days a week.

Premium Payment Address Change If you pay a monthly premium for your Medicare Advantage plan, please note that Network Health has a new post office box for Medicare Advantage plan premium payments.

To ensure timely receipt of monthly premium payments, please use this new mailing address.

networkhealth.com

Network Health Insurance Corporation P.O. Box 78424 Milwaukee, WI 53278-8424 C oncierge | 5

life. health. wellness.

Stay Active to Improve Balance and Prevent Falls

By SilverSneakers®

R

egular exercise makes you stronger, more stable and more confident. More confidence means walking to the kitchen, the mailbox or through the grocery store without worrying about falling. It means getting dressed and climbing stairs without giving it a second thought.

Confidence allows you to join a hiking group, play ball with your grandkids or bring your bike out of retirement.

In fact, any time you use your hands and eyes, your hands and feet, or two sides of your body at the same time, you’re relying on coordination. Regular exercise can improve your coordination, balance and strength. More importantly, it can increase your independence and quality of life. You’ll probably have more fun too.

Choose fitness over fear

Feeling old is not an inevitable part of getting older, so don’t let a fear of injury keep you on the couch. Exercise can enrich your life in many ways. You have the power to choose fitness over fear, and to live your best life. What are you waiting for?

“

Balance is a separate system, just like strength or flexibility. You can improve it if you continue to challenge it.

“

Many people let a fear of falling keep them from being active. Safe, appropriate physical activity can improve your coordination and reduce your risk. It’s very important to keep moving and challenging yourself. “Balance is a separate system, just like strength or flexibility. You can improve it if you continue to challenge it,” says Edward Laskowski, MD, codirector of the Mayo Clinic Sports Medicine Center in Rochester, MN.

Edward Laskowski, MD, codirector of the Mayo Clinic Sports Medicine Center in Rochester, MN.

Always talk with your doctor before starting an exercise program. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/ SilverSneakers and the SilverSneakers shoe logotype are registered trademarks of Tivity Health, Inc. © 2019 Tivity Health, Inc. All rights reserved.

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networkhealth.com

…you can get a routine eye exam for just $10?

Network Health covers your annual routine eye exam for a $10 copayment. An annual routine eye exam is important to check your vision, update your prescription and spot early warning signs for other health conditions.

Our network for routine eye exams is different than our network for medical eye exams. Make sure you visit networkhealth.com/medicare/additional-benefits for more information and to find an in-network provider.

…you can get an annual dental exam and cleaning for just $30?

We know it’s important to protect your teeth and gums with preventive dental care, so Network Health covers one annual exam and cleaning with an in-network dentist for a $30 copayment. Visit networkhealth.com/medicare/ additional-benefits for more information and to find an in-network dentist.

Not available on Network Health PlatinumSelect or Network Health Medicare Go.

…you can get your generic Tier 1 prescriptions for $0?

Simply sign up for mail-order delivery and you can get up to a 90-day supply of your Tier 1 prescriptions delivered to your home for $0. By using prescription mail-order, you can save money, save a trip to the pharmacy and get automatic refills. To sign up and learn more, visit networkhealth.com/medicare/ pharmacy-information or call 800-316-3107.

networkhealth.com

…you can see a doctor from the comfort of your own home?

Network Health covers virtual visits that give you 24/7 access to board certified physicians over the phone, internet or through a convenient app—at no cost to you. Online or telephone visits with a physician are a convenient and affordable alternative to urgent care or an in-person doctor visit if your personal doctor is not available. Visit networkhealth.com/wellness/gettingcare-quickly to learn more.

…you can work with a pharmacist to save money on your prescriptions drugs?

Network Health offers a Medication Therapy Management program. Our Network Health pharmacists will work with you to ensure you’re on the most appropriate and cost-effective medications, improve your medication use and reduce your risk of dangerous drug reactions. Visit networkhealth.com/wellness/medication-therapymanagement to see if you’re eligible.

…you can work out at a gym, or from home?

Your Network Health fitness benefit isn’t just a gym membership. You have access to over 16,000 fitness centers nationwide, senior-focused fitness classes, at-home fitness kits and online video workouts.

Visit networkhealth.com/wellness/silversneakers to learn more.

Not available on Network Health PlatinumSelect.

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life. health. wellness.

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The Buzz About Continuous Glucose Monitoring

W

e all know that people with diabetes use diabetic test strips to check their blood sugar levels.

Checking blood sugars regularly helps maintain control of diabetes. Network Health covers the One Touch® and Accu-Chek® test strips at $0 for most* Network Health Medicare Advantage members. There are other options to check blood sugars, including a Continuous Glucose Monitoring (CGM) system.

Network Health covers two CGM systems—Dexcom® and FreeStyle Libre. Each has its own unique features for monitoring blood sugar levels, so you and your personal doctor can work together to select the most appropriate system. Keep in mind these systems require a prior authorization by your personal doctor.

A CGM continually monitors blood sugar levels, giving members more freedom and keeping blood sugar under control. Additionally, CGMs don’t require daily finger sticks to check blood sugar. While a CGM is not for every person with diabetes, if you qualify and are interested in learning how these new meters work, it may make a big difference in your treatment. *NetworkCares members pay $0.50.

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networkhealth.com

Network Health is one of only two Medicare plans that cover these two CGMs at $0 when obtained at a retail pharmacy.

Other plans cover them through a Durable Medical Equipment (DME) benefit and bill 20 percent of the CGM system cost to the member.

The CGM systems are another way Network Health helps our diabetic members improve their long-term health. If you’re interested, contact the Network Health pharmacy team at 920-720-1696 for a brochure that reviews these two systems in more detail.

Understanding Vaccine Coverage under Medicare Medicare vaccinations can fall under Part B or Part D coverage. Getting your Part D vaccines at a retail pharmacy is the lowest cost option, compared to receiving them at the doctor’s office.

Which vaccines are covered under Medicare Part B? • Hepatitis B vaccine for patients at high or intermediate risk • Influenza vaccine • Pneumococcal vaccine (for example, Prevnar13 and Pneumovax 23) • Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition (for example, a tetanus shot after suffering a puncture wound)

Which vaccines are covered under Medicare Part D?

• No vaccines that are already covered under Medicare Part B • All other commercially available vaccines, as long as it is deemed reasonable and necessary to prevent illness • Examples include Shingrix, tetanus boosters (not used for treatment, injury, or direct exposure to a disease) For additional information about part D vaccines, the Centers for Medicare & Medicaid Services (CMS) has a helpful booklet online at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/

New Quality Improvement Organization Earlier this year, Livanta became the new beneficiary and family centered care Quality Improvement Organization for the Centers for Medicare & Medicaid Services (CMS) in Wisconsin.

Livanta conducts medical case review, supporting the rights of people on Medicare. These rights include protecting you when you get health care and making sure you get the health care services the law says you are entitled to. Livanta can help you if you have a concern about the care you have been receiving or if you want to request a review (appeal) of your discharge from a health care facility.

Livanta can be reached at 888-524-9900 (TTY 888-985-8775).

networkhealth.com

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COVER STORY

Preventive

care

—

A He Says, She Says Story

The fact that preventive care is important isn’t groundbreaking news. We understand we need to make our health a priority, and yet, sometimes it’s still a struggle and we fall short.

Dennis and Cathy Ellisen, from Appleton, explain why routine preventive care is the key to living your best life.

They believe in preventive care for different reasons, something many can relate to.

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networkhealth.com

By Romi Norton, Photography by Beth DesJardin, Trove Photography networkhealth.com

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[ He Says[

COVER STORY

Dennis is a “re-retired pastor” who came to the Fox Cities area from New York in 1976, after being recruited to serve as a fulltime pastor at Our Saviour’s Lutheran Church on Meade Street in Appleton. He retired around eight years ago. Shortly after that, a church leader approached him and asked if he would help at Our Saviour’s Lutheran Church in Neenah. Dennis decided to come out of retirement to help the church. “Our church is very involved with international missions and does a lot of community work. It’s a nice church,” said Dennis.

Taking care of his health and wellness gives Dennis the chance to continue to be involved in the community. “We’ve been blessed, because we’re fairly healthy. I say I’m fairly healthy and I’ve had prostate cancer, my hip replaced, rotator cuff surgery and hand surgery. But other than that, I am really fairly healthy,” said Dennis with a smile.

Dennis’ prostate cancer was discovered through a routine prostate-specific antigen (PSA) test screening. “My doctor monitored the PSA levels for about six months. I must have had at least six biopsies. We had determined it was cancer and wanted to find exactly where it was,” said Dennis.

Luckily, Dennis is always consistent with his annual wellness visits and routine screenings, improving his odds of beating prostate cancer. “We always go for our annual visits, that’s basically all we need,” continued Dennis.

Now cancer-free, with a new hip, repaired shoulder and hand— Dennis stays busy and active playing golf, attending many sporting events to cheer on his grandchildren and traveling. On one of his trips, he discovered another benefit of being proactive with his care. He and Cathy were on a road trip to Brooklyn, New York, when they both were not feeling well. They decided to get care right away, rather than trying to stick it out. After all, it’s hard to enjoy your vacation when you’re feeling under the weather. They checked out a local urgent care center and discovered they both had bronchitis. “We paid the copayment and it was all taken care of. It’s nice to know, because we do travel a lot,” said Dennis.

Many times, you don’t know the benefits of your health plan until you need to use them, and that’s when it truly matters.

From preventive screenings to coverage when you travel, it’s important your health plan is there. “Nothing is complicated.

That’s what I like. It’s quite simple,” said Dennis when asked to describe his Network Health plan.

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networkhealth.com

[ She Says[ Cathy has her own experience. She learned about Network Health before she was on Medicare. “I worked in Medicare sales. I loved doing seminars and educating people about their benefits, because Medicare was so new to them. I felt that people walked out knowing what their choices were. That was a fun time,” said Cathy.

When she retired, her Medicare Advantage plan choice was easy.

She chose Network Health because it’s a local company with exceptional customer service. “I knew if I ever had a question, I could just go right in and get answers; it means a lot. Peace of mind is important to me,” said Cathy.

When asked about her preventive care, Cathy explains how important it is to stay healthy. “It’s huge—without good health, all the things we enjoy would not be possible. I keep active and always have my annual,” said Cathy.

Cathy spends her time visiting her 94-year-old mother, golfing, gardening, traveling and attending her grandchildren’s sporting events. She understands the importance of staying active and healthy, so she can continue doing what she loves. Cathy also enjoys being active in the community as a volunteer at LEAVEN in Menasha. “It’s so hard sometimes to hear what people are going through. I love it, being able to help people,” said Cathy.

What Is Preventive Care?

Preventive care includes annual wellness visits, vaccinations, labs and screenings, as well as programs to check your health and health education. Recommended services vary depending on your age, gender, current health status and individual risk factors. Your personal doctor can help you determine which services are right for you.

Keeping Track

It can be tough keeping the recommended preventive care and screenings straight. Your Network Health Member Guide includes a Preventive Health Checklist to help you keep track of the services you receive and which you still need.

Take the checklist to your appointments to discuss next steps with your personal doctor to ensure you are taking advantage of all the preventive services available to you. You can also find the Checklist online at your secure member portal at login.networkhealth.com under My Materials. networkhealth.com

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Lifecycle of a Claim H 2 ave you ever wondered what happens to your claim between the time you go to the doctor and the time you receive your bill?

STEP

1

After you go to the doctor, his or her office will file a claim for the service(s) provided. Each service has a procedure and diagnosis code. The procedure code tells us what was done during the visit and the diagnosis code tells us why. It’s important to ask your doctor about the procedures they are performing and how they are being coded. This can help you avoid surprises when your Explanation of Benefits (EOB) arrives.

STEP

Claim Filed

Each claim has its own lifecycle, containing several steps to Your claim is filed with Network Health, either confirm accuracy. electronically or through the mail. Claims that are received electronically automatically load into our system. Paper claims are dated when they are received and converted into electronic files or manually entered into our claims processing STEP system.

4

STEP

5

Verified When your claim is processed, we ensure your insurance coverage was effective on the date you received the service. Our processing system automatically verifies the service is covered.

STEP

6

STEP

3

Claim Processed

The Network Health claims processing system is set up to match your benefits, and your claim is either processed automatically or reviewed by a claims analyst. This process ensures accuracy of the claim.

Reviewed

Your claim and benefits are reviewed.

This review also determines if you owe out-of-pocket costs. Then, our system notifies your doctor what you owe.

STEP

Explanation of Benefits (EOB)

We pay the eligible amount—minus any out-of-pocket costs, such as coinsurance or copayments—directly to the provider. You receive your EOB, explaining how your claim was processed. The EOB is not a bill—it’s a breakdown of how your claim was processed.

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Doctor Visit

7

Billing

Once Network Health pays your doctor, it’s posted to your record, which you can view from the member portal at login.networkhealth.com. Your doctor’s office sends you a statement showing the remaining amount you owe—if anything.

It’s important to compare the provider bill to your EOB to ensure you are being billed the correct amount.

networkhealth.com

Join

a Precision Medicine Research Program

By Froedtert Health

T

he National Institutes of Health All of Us Research Program has a simple mission—to speed up health research breakthroughs. To do this, All of Us is asking one million or more people from diverse backgrounds to share their health information.

Froedtert and the Medical College of Wisconsin, along with Versiti Wisconsin, Inc., are part of the All of Us Wisconsin cooperative, which includes Marshfield Clinic Research Institute and the University of Wisconsin School of Medicine and Public Health.

The goal of All of Us is to advance precision medicine or health care based on you as an individual. It considers factors like where you live, what you do and family health history. Precision medicine outlines the best ways for you to stay healthy and may help health care teams find the best treatment if you get sick.

Participants will share information about their health over time. Researchers will then study this data to determine how to improve health for future generations.

To learn more, visit Participant.JoinAllofUs.org, email allofus@mcw.edu, or call 833-629-2638.

To start your journey right away, go to Participant.JoinAllofUs.org and follow these steps.

1. Create an account 2. Give your consent 3. Agree to share your electronic health records 4. Answer health surveys 5. If requested, have your measurements taken (height, weight, blood pressure, waist and hip size) and give blood and urine samples Participants completing all registration steps not only have a chance to personally support medical research, but will also receive a $25 gift card in appreciation for their time and commitment. Consider joining today.

Breaking Down Barriers to Care

By Alice Parks, director population health with Network Health ou may have heard the phrase “social determinants of health.” The World Health Organization defines it as “the conditions in which people are born, live, learn, work, play, worship and age that affect health outcomes and risks, functioning and quality of life.” This means many factors in your life, outside of health care itself, can affect your health and wellness. Sometimes those factors can become barriers or challenges to feeling well and being healthy.

Y

What barriers do some people face?

Here are some to consider.

• Religious, spiritual, or cultural beliefs and values that aren’t understood by a health care team

Ask yourself these questions.

• What barriers do I face to feeling well and being healthy?

• What can I do to break down those barriers?

And then, take action. For example, if you or a family member has a language barrier, ask for a translator. Or if a suggested treatment plan conflicts with your values, let your health care team know. They can offer alternative care plans.

• Enough money to cover basic expenses, like food Remember, Network Health is here to support you on your • A place to live health and wellness journey. We have nurses and social • Access to transportation to get to the grocery store, the work care managers right here in Wisconsin to discuss the doctor, a support group or social activities challenges you’re facing. We’ll help you find resources • People to check in or provide support within the community to break down some of those barriers.

• The ability to understand information about health— medical jargon can be hard to understand and sometimes To learn more, call 866-709-0019 (TTY 800-947-3529), we speak and understand different languages Monday–Friday from 8 a.m. to 5 p.m.

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life. health. wellness.

The

Service YOU

DESERVE

t Network Health, we make every effort to ensure you’re receiving the service you need and deserve. If concerns arise, we want to make sure you understand all your options. If you do not agree with Network Health’s decisions about your care or what’s covered, you have the right to file an appeal or grievance. We have a team of appeals and grievance specialists who will work with you throughout this process.

When do I file an appeal?

You have the right to file an appeal if you do not agree with Network Health’s decisions about your health care.

You can submit an appeal in writing within 60 calendar days from the date you receive the claim denial. Your written appeal should include your full name, member ID and information about what you are appealing. You may also include any comments, documents, records or other information you would like Network Health to consider in its review.

Examples of situations appropriate for an appeal include the following.

Network Health did not approve care it should cover.

Network Health is stopping care you still need.

Network Health has denied payment for services or items you have received and you think they should be covered. n n n

Who may file an appeal?

You or someone you name to act for you (called your representative) may file an appeal. A Durable Power of Attorney agreement can work in place of an Appointment of Representative form. You don’t have to fill out an Appointment of Representative form if a Durable Power 16 | C oncierge

of Attorney agreement is in place. The latter covers all care decisions. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. To name your representative, visit networkhealth.com, select Medicare Plans, Member Resources and scroll down to the Appointment of Representative form. Simply complete this form and send it to us.

What happens after I file an appeal?

If you appeal, we will review our decision. If payment for any of your claims is still denied after our review, we will automatically forward your Part C appeal request to the Medicare contractor (MAXIMUS Federal Services) for an independent review. This process is provided by Medicare for a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with that decision, you will have further appeal rights and you’ll be notified of those appeal rights if this happens.

How are medication appeals handled?

Medication appeals are reviewed by a Network Health Pharmacist and Network Health Medical Director, as needed. The pharmacist communicates with the prescribing provider if additional information is needed, or he/she may discuss alternative covered medications. networkhealth.com

Our pharmacists have a goal of addressing medication appeals within four hours.

They have been successful over 90 percent of the time. This means better customer service for both physicians and you as a member.

When do I file a grievance?

If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about how Network Health, our vendors or contracted providers provided services.

Examples of situations appropriate for a grievance include the following. n n n n

Concerns about the quality of care of services provided Interpersonal aspects of care (for example, rudeness of a provider or staff) Difficulty getting through on the phone Failure to respect your rights

You can submit a grievance over the phone or in writing within 60 calendar days from the date of the event.

See the Contact Information provided.

Contact Information Appeals and Appointment of Representative Form Call: Health Care Concierge Team at

800-378-5234 (TTY 800-947-3529)

Monday-Friday, 8 a.m. to 8 p.m.

Fax: 920-720-1832 Write: Network Health

Attn: Medicare Advantage Plans P.O. Box 120 Menasha, WI 54952 networkhealth.com

Grievance

Call: Health Care Concierge Team at

800-378-5234 (TTY 800-947-3529)

Monday-Friday, 8 a.m. to 8 p.m.

Fax: 920-720-1832

Write: Network Health

Attn: Appeals and Grievances

P.O. Box 120

Menasha, WI 54952

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life. health. wellness.

What Happens When We Focus on Quality

By Lisa Boucher, BS, accreditation program manager for Network Health

Network Health is known for providing high-quality service. You experience it through our health care concierge team and our provider partners that bring you exceptional care. Our focus on quality shows in our member ratings, which are higher than the national average.

Customer CustomerService Composite

Service Composite

Getting Needed Care Getting Needed Composite

Care Composite

Personal Personaldoctor doctor explained things explained in a way that was things in a way easy to understand

that was easy to understand

Personal Personaldoctor doctor listened carefully listened to patient

carefully to patient

97.4%

96.4%

97.0%

96.0%

93.5%

95.6%

Medicare Medicare

Personal Personal Personaldoctor doctor Personaldoctor doctor spent enough time showed respect for spend enough showed respect with patient what patient had to say

time with patient

for what the patient had to say

For more information on Network Health’s Quality and Performance Improvement Program, please call your health care concierge team at 800-378-5234 (TTY 800-947-3529) or email the quality health integration department at QI@networkhealth.com.

The source for data contained in this publication is Quality Compass® 2018 and is used with the permission of the National Committee for Quality Assurance (NCQA). Any analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA.

Know Your Member Rights and Responsibilities Did you know you have rights and responsibilities as a Network Health Medicare member? To learn more about how we provide you with service that respects your rights, go to networkhealth.com, select Medicare Plans and Member Resources. On this page, you’ll find Member Rights and Responsibilities. You can also call customer service at 800-378-5234 (TTY 800-947-3529) Monday– Friday, from 8 a.m. to 8 p.m. to request this information.

18 | C oncierge

Access to Network Health Care Management Associates and Services Network Health assures access to medical and behavioral health care management associates for Medicare Advantage members and their providers and office staff seeking information about our care or utilization management programs. If you have questions about the care or utilization management program, please contact care management at 866-709-0019 (TTY 800-947-3529), Monday– Friday from 8 a.m. to 5 p.m.

networkhealth.com

Evaluating New Technologies

Do you ever wonder why new benefits are added to your health plan and why coverage changes?

By Natalie Knaack, RN, BSN, manager population health for Network Health

N

etwork Health’s Medical Policy Committee (MPC) evaluates new technology or new ways of using existing technologies on a regular basis.

The evaluation process considers effectiveness of the technology, its appropriate use and evidence. Network Health also follows the Centers of Medicare and Medicaid Services (CMS) coverage determinations and technology assessments.

Decision-making on technologies is based on, but not limited to, the following.

n Scientific evidence

n Information from government regulatory agencies

n Risk/benefit analysis

n Manufacturer information

n Assessments done by agencies specializing in technology

n Opinion of provider experts

The following technology assessments have been completed over the past 12 months.

Technology Review

Outcome

Zio XT/ZioPatch cardiac monitors

Network Health determined that this technology is safe and effective.

ClariVein (treatment for varicose veins)

Network Health has determined that this treatment is safe and effective. A new medical policy for varicose vein procedures has been developed.

If you have a question about a technology assessment, contact our care management department at 866-709-0019 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 5 p.m.

A Special Delivery, Just for You You asked, and we listened. To thank you for your valuable feedback, we want you to know about changes we’ve made.

1. Be on the lookout for your 2020 member ID card. We are sending your 2020 ID card in October, so you can be ready when the new plan year begins.

2. Save the trees. You can request paperless electronic Explanation of Benefits (EOB) documents through your secure online member portal. You’ll receive an email each time there’s a new EOB available. Create your account today at login.networkhealth.com. networkhealth.com

C oncierge | 19

PRESORT STD US POSTAGE PAID GREEN BAY, WI PERMIT NO. 1033

1570 Midway Pl. Menasha, WI 54952 Health and wellness or prevention information

Get Social (For Real) W

e want you to venture out and explore the real world. Below, you will find a brief highlight of special events in our community. For more fun, follow Network Health Wisconsin on Facebook.

WHEN

WHAT

WHERE

October 12

Panther Prowl 5k run/walk • uwm.edu/pantherprowl/

Milwaukee

October 14

Fox Valley Memory Café www.kaukaunalibrary.org/event/fox-valley-memory-cafe

Kaukauna Library

Halloween Tricks and Treats – Cooking Workshop www.nutritionalhealingllc.com/community/

Nutritional Healing, Appleton

Mindful Movement • www.pulsecedarburg.com

Cedarburg

October 19

Mosquito Hill Endurance Run www.calendar.ultrarunning.com/event/mosquito-hill-endurance-run

New London

October 21

Fall Wreath Workshop • www.milwaukeepublicmarket.org

Milwaukee

October 27

Pumpkin Run 5k • www.racelighthouse.com/pumpkinrun

Oconomowoc

October 28

Classic Italian Pasta Dishes • www.milwaukeepublicmarket.org

Milwaukee

October 31

Pumpkin Walk • www.cedarburg.org/events

Cedarburg

November 2

Houdini 10k • www.runawayshoes.net/houdini10k

Appleton

November 21

Explore Network Health • networkhealth.com/medicare/events

Menasha and Brookfield

November 23

Milwaukee Turkey Trot 8k & 5k www.wisconsinruns.com/milwaukeeturkeytrot

Milwaukee

November 24

Noodleini Half Marathon www.racethread.com/race/noodleini-half-marathon

De Pere

November 28

Festival Foods Turkey Trot • www.festivalfoodsturkeytrot.com

Appleton, Oshkosh, Manitowoc, Green Bay and Fond du Lac, WI

November 28

De Pere Turkey Trot 5k • www.wisconsinruns.com/depereturkeytrot

De Pere

October 16

Listed events are accurate at the time of printing.