Provider Resources

Our Provider Support team is here to help you and your practice. If you have questions about network participation, processes, resources, or need assistance navigating provider requirements, we’re ready to help. We encourage you to reach out to one of our Provider Hotlines if you need guidance or additional support.

Provider Hotlines

Therapy – Georgia: 855-825-7818, option 1

Therapy – New Jersey: 855-825-7818, option 2

Therapy – Florida: 888-550-8800, option 4

Therapy – Puerto Rico: 877-614-5056, option 2

Dermatology, Podiatry, Gastroenterology, and Urology: 800-595-9631, option 2

Eye Management – EMI: 800-329-1152, option 2

Eye Management – Premier: 800-738-1889

We follow each health plan's Prior Authorization Lists (PAL). For specifics on what requires prior authorization, please refer to the member's health plan website.

For services that require prior authorization or a control number, providers may submit for authorization requests via the Provider Web Portal or via fax. Please refer to your state and provider handbook for details on what is needed for your specific authorization request and, if needed, a fax number.

Services are reviewed as quickly as possible and we follow the timelines set by CMS, the state or each health plan for the member.

The organization follows: CMS guidelines to include National Coverage Determinations (NCD) and Local Coverage Determinations (LCD); Health Plan partner Clinical Guidelines (depending on the LOB) for any medical necessity determinations or, if nonapplicable, will use MCG or Apollo Clinical Guidelines to support benefit determinations. These guidelines are based on appropriateness and medical necessity standards. Each guideline is current and has references from the peer-reviewed medical literature, and other authoritative resources such as CMS Medicare.

For any medical necessity Denial or Recommendation of Denial, the Medical Director shall attempt to contact the requesting provider for peer-to-peer consultation. Applied Clinical Guidelines are available in both electronic and hard copy format. If a provider would like a copy of the guidelines, they may contact their assigned Provider Relations Representative, and a copy will be provided. You may also access them with the following links:

• National Coverage Determinations

• Local Coverage Determinations

• Apollo

• MCG (link to follow) 

For health plan specific guidelines, please refer to the member's health plan website.

Affirmative Statement about Utilization Management Decision Making

All clinical staff that make Utilization Management (UM) decisions are required to adhere to the following principles:

• UM decision making is based only on appropriateness of care and service and existence of coverage.
• The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
• Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
• Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to support benefit denials.

Annually, the Quality Improvement (QI) Department develops quality documents, which includes a QI & Utilization Management (UM) Evaluation, Program Description, and Work Plan. The development of the quality documents satisfies health plan and NCQA Accrediting body requirements. The QI & UM evaluation analyze the QI department's previous year quality indicators, key accomplishments, identify any areas needing improvement, and develop action plans to improve results. The program description and work plan establish objectives, goals, QI activities, and the QI program structure for the current year. Copies of the annual QI documents are available by contacting the QI department at QI@healthnetworkone.com

Members with Limited English Proficiency (LEP) may not understand health information concerning their care:

• The organization will provide language assistance services to individuals with LEP and facilitate effective communication for the patient.
• The organization will provide notice about the availability of language assistance services and auxiliary aids and services to patients at no extra cost. For individuals with disabilities and the Dual Eligible Special Needs Plans (D-SNPs) population who require auxiliary aids and services, these notices will be provided in alternative formats to ensure effective communication to patients at no extra cost.
• The notices will be provided annually, upon request.
  

To help ensure smooth communication and uninterrupted support, it’s important that we have the most up‑to‑date information for your practice. We regularly communicate with providers about important updates that may impact operations, participation, or payment.

If you have any changes to your practice—such as demographic updates, provider additions or terminations, or other office changes—please notify us. You may reach out by email by contacting one of our Provider Support teams with your updates.

Therapy

Florida: TNFL@healthnetworkone.com

Georgia: TNGA@mytnga.com

New Jersey: TNNJ@healthnetworkone.com

Puerto Rico: TNPRProviderRelations@mytnpr.com

Dermatology, Podiatry, Gastroenterology and Urology:  NetworkManager@healthnetworkone.com

Eye Care

EMI: info@eyemanagementinc.com

Premier Eye Care: DataIntegrity@premiereyecare.net