Provider Manual

Member Information

Information on member rights and responsibilities, determining eligibility, and other member information.

Network Operations

Information on provider communications, provider collection policy, credentialing, coordination of benefits and subrogation, quality management, clinical standards, administrative procedures, professional credentialing and recredentialing, serious reportable events and never events.

Medical Management

Information on behavioral health, prior authorizations, clinical policies, pharmacy, care management, utilization management, behavioral health, procedures subject to UM (non BH), radiology, sleep studies and genetic testing, pharmacy services, durable medical equipment, allowable lab procedures, and a link to a separate clinical policies web page.

Health Care Quality

Information on quality improvement, measurement and management activities, clinical guidelines and standards, HEDIS, NCQA accreditation, quality improvement program.

Health New England Products and Benefits

Information on Health New England plans, products and benefits and links to Charts of Benefit documents.

Billing and Reimbursement

Information on claims submission and reimbursement, coordination of benefits and subrogation, serious reportable events and never events.

Payment Policies

Payment methodologies that apply to submitting claims.

Appeals

Guidelines and forms to submit a provider appeal and access to the claim review form.

Online Solutions

Information on HNEDirect.