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PPO members - Find a PHCS or Multiplan provider.
Find participating urgent care facilities in the area.
Find participating hospitals in the area.
Search the Optum Health database for participating chiropractic providers.
Search Find an Altus Dental provider in your area.
Find participating lactation counseling providers in our network.
Find participating acupuncture providers in our network.
At Health New England, we are committed to keeping health care information simple and easy to access. From policies and procedures to forms and documents, you'll find what you are looking for here.
ACO Home Care Partnership: With the Accountable Care Organization, there are certain guidelines to follow when requesting services, how to submit requests and billing procedures. In fact, the type of professional services allowed is based on the degree of skills as it relates to the medical necessity of the member. Health New England is here to help you understand and partner for the care of our members. Below is information necessary for you to know.
Requirements and Guidelines: Reference the ACO Home Care Partnership Booklet to learn more about authorization requirements and guidelines around type of services and payment guidelines.
Commonly Used Managed Codes and Descriptions: Reference the Home Care Service Code Description Card to understand the best practices with the various codes used for each services. Frequently Asked Questions (Coming Soon)
At Health New England, we want our members to know there are alternative methods for managing pain than just simply using medication. While we understand the need for some medication, we want providers to be aware of the various options our plans offer for pain treatment.
We hope the following information will support discussions with your patients, who are also Health New England commercial plan members, about their options.
Pain Management Alternatives offered by Health New England:*
Abdominal Panniculectomy Revised Effective 12/1/20
Absorbent Products
Ambulatory Electrocardiography Effective 1/1/21
Antibody Testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) New Effective 2/1/21
Admission and Concurrent Review for Substance Use Disorder Inpatient RehabilitationRevised Effective 5/7/2020
Afirma Thyroid FNA Analysis Testing Archived Effective 6/12/18
Artificial Intervertebral Cervical Disc Effective 2/1/20
Artificial Intervertebral Cervical Disc Revised Effective 2/1/21
Azedra New Effective 12/1/20
Balloon Dilation of The Eustachian Tubes Effective 1/1/21
Bone Grafts for Spinal Defects Revised Effective 8/1/2020
BH ABA for Autism Spectrum Disorders Revised Effective 5/7/2020
BH Admission and CSS Revised Effective 11/5/20
BH ART
BH CBAT Revised Effective 11/5/20
BH CSU Revised Effective 11/5/20
BH Day Treatment Revised Effective 5/7/2020
BH FST Revised Effective 11/5/20
BH Psych Testing
BH Transcranial Magnetic Stimulation Revised Effective 2/1/20
BH Transcranial Magnetic Stimulation Revised Effective 2/1/21
Biofeedback for Urinary Diagnoses Effective 5/12/2020
Blepharoplasty and Browplasty Effective 6/1/20
Blepharoplasty and Browplasty Revised Effective 6/1/21
Bronchial Thermoplasty Effective 2/1/20
Bronchial Thermoplasty Revised Effective 2/1/21
Centers for Medicare & Medicaid (CMS) and MassHealth Criteria and Guidelines Revised Effective 4/1/18
Chimeric Antigen Receptor T-Cell Therapy (CAR-T Cell Therapy) Effective 2/1/2020
Chimeric Antigen Receptor T-Cell Therapy (CAR-T Cell Therapy) New Effective 2/1/2021
Chondrocyte Transplant to the Knee Archived Effective 1/1/2021
Clinical Trials Revised Effective 8/1/2020
Clinical Trials - Medicare Revised Effective 8/1/2020
Clinical Review Criteria for Short Acting Opioids
Clinical Review Criteria Related to TMS Revised Effective 11/5/2020
Cochlear Implants and BAHA (Bone Anchored Hearing Aid) Revised Effective 12/1/20
Cologuard DNA Stool Test Archive Effective 1/9/2018
Contact Lenses (Formerly Scleral Lens) Effective 12/1/20
Continuous Glucose Monitoring System Archived Effective 6/13/17
Corneal Cross Linking Effective 2/1/20
Corneal Cross Linking Revised Effective 2/1/21
Cranial Orthoses
Deep Brain Stimulation Treatment New Effective 1/1/21
Drug Testing Effective 1/13/20
Drug Testing Revised Effective 2/1/21
Endothelial Keratoplasty Revised Effective 12/1/20
Endovenous Ablation Therapy for Varicose Veins Effective 7/1/20
Endovenous Ablation Therapy for Varicose Veins Revised Effective 6/1/21
Female Breast Reduction (formerly Reduction Mammoplasty) Revised Effective 4/1/2021
Fecal Microbiota Transplant Archived 5/12/20
Formula and Enteral Nutrition Revised Effective 12/1/20
Gait Trainers (MassHealth) Effective 4/1/18
Gardasil Protocol-HPV Vaccine
Gastric Electrical Stimulation Effective 2/1/20
Gastric Electrical Stimulation Revised Effective 2/1/21
Gender Reassignment Effective 4/1/20
Gender Reassignment Revised Effective 4/1/2021
Genetic Testing Archived Effective 6/12/18
High Frequency Chest Wall Oscillation Devices Archived Effective 4/9/19
Home Health Care Services - Medcaid Effective 2/1/20
Home Health Care Services - Medcaid Effective 2/1/21
Home Use of Oxygen Archived 10/1/18
Hospital Beds (MassHealth) Effective 4/1/18
Hydrogen Breath Testing Revised Effective 12/1/20
Hyopbaric Oxygen (HBO) Therapy Revised Effective 4/1/20
Hyopbaric Oxygen (HBO) Therapy Revised Effective 4/1/2021
Implantable Miniature Ocular Telescope Prosthesis Archived Effective 5/14/19
Intacs Corneal Implants Effective 9/1/20
Intacs Corneal Implants Revised Effective 12/1/20
Infertility Protocol Revised Effective 7/1/20
Knee Arthroplasty and Knee Arthroscopy for MassHealth Archived Effective 1/1/2021
Knee Braces Revised Effective 9/1/20
Laser-Assisted Uvulopalatoplasty or Uvulopalatopharyngoplasty Revised Effective 9/1/20
Lutetium LU 177 Dotatate, Therapeutic Effective 11/13/19
Lutetium LU 177 Dotatate, Therapeutic Revised Effective 2/1/21
Mandibular Advancement Device (MAD) in the Treatment of Obstructive Sleep Apnea Archived 6/11/19
Medical Necessity Revised Effective 7/10/2019
Neuropsychological Testing for Medicare Advantage Members Revised Effective 5/7/2020
Nodify Lung Nodule Risk Assessment - New Effective: 12/1/2020
Non-Covered, Experimental & Investigational Services Effective: 7/1/2020
Non-Covered, Experimental and Investigational Services Revised Effective 2/1/21
Orthognathic Surgery Revised Effective 12/1/2020
Outpatient Physical, Occupational and Speech Therapy Revised Effective 9/1/21
Percutaneous Left Atrial Appendage Closure Revised Effective 12/1/20
Photochemotherapy, Phototherapy, Laser Treatments Effective 6/1/20
Photochemotherapy, Phototherapy, Laser Treatments Revised Effective 6/1/21
Positive Airway Pressure Archived Effective 4/4/17
Preimplanataion Genetic Diagnosis (PDG) Effective 6/1/20
Preimplanataion Genetic Diagnosis (PDG) Revised Effective 6/1/21
Proton Beam Therapy Revised Effective 9/1/20
Radiofrequency Ablation Effective 6/1/20
Radiofrequency Ablation Revised Effective 6/1/21
Reconstructive Breast Surgery Revised Effective 1/1/2021
Reconstructive Repair of Pectus Excavatum or Pectus Carinatum Revised Effective 12/1/20
Rhinoplasty Revised Effecitve 12/1/2020
Sacral Nerve and Electrical Percutaneious Tibial Nerve Stimulation Effective 9/1/20
Sacral Nerve and Electrical Percutaneious Tibial Nerve Stimulation Revised Effective 2/1/21
Sacroiliac Joint Fusion Effective 9/1/2020
Skin and Soft Tissue Substitutes Effective 11/13/19
Skin and Soft Tissue Substitutes Revised Effective 2/1/21
Speech Generating Devices Archived 6/11/19
Speech Therapy Revised Effective 9/1/20
Speech Therapy for Autism Disorders Effective 6/1/20
Speech Therapy for Autism Disorders Revised Effective 4/1/2021
Spinal Cord Stimulation Effective 6/1/20
Spinal Cord Stimulation Revised Effective 6/1/21
Stretta Procedure Archived Effective 12/2/18
Standers (MassHealth) Effective 9/1/18
Support Surfaces (MassHealth) Effective 9/1/18
Surgical Management of Morbid Obesity Effective 12/1/20
Surgical Management of Morbid Obesity Revised Effective 4/1/2021
Surgical Treatment of Gynecomastia Effective 4/1/20
Surgical Treatment of Gynecomastia Revised Effective 4/1/2021
Therapeutic Shoes and Orthotics Revised Effective 12/1/20
Total Ankle Replacement Revised Effective 9/1/20
Total Hip Resurfacing Archived 6/9/20
Transanal Endoscopic Microsurgery (TEMS) New Effective 4/1/2021
Transplants and Ventricular Assist Devices Effective 9/1/2020
Treatment of Lipodystrophy Syndrome (LDS) Revised Effective 12/1/20
Tumor Treatment Fields (TTFs) (i.e., Optune Device) Revised Effective 12/1/20
Upper Airway Stimulation Device (UAS) / Hypoglossal Nerve Stimulation (HGNS) (Inspire) Revised Effective 9/1/20
Water Vapor Thermal Therapy (Rezum) New Effective 2/1/21
Wearable Cardiac Defibrillator Archived 6/9/20
(Genetic Lab, High Cost Imaging, Sleep Study Program)
For more information about eviCore, please go to www.evicore.com
To access the commonly used managed codes for Genetic Lab, Sleep Study Program or High Cost Imaging, log on to the eviCore portal.
eviCore FAQs
eviCore Web Enhancements
Northwood, Inc. (Northwood), a durable medical equipment benefit manager (DBM) will manage a full range of services and provider types in order to administer DMEPOS benefit for Health New England’s Commercial, Medicare Advantage and Medicaid members.
The services they will provide are as follows:
The following provides the various provider types Northwood will manage. However, there are some exceptions where Health New England will step in. To help answer when to work with Northwood vs. Health New England, please reference the materials below. For additional provider information, please visit Northwood's website.
Provider Types Managed by Northwood vs. Health New England
Northwood Managed Codes
Northwood Commercial/Medicare Medical
Northwood Medicaid Medical Policies
Provider FAQs
Fraud Waste and Abuse Prevention
HIPAA X12 standards, version 5010, is a new standard that regulates the electronic transmission of specific health care transactions. Covered entities – health plans, health care clearinghouses, and health care providers adopted HIPAA 5010 standards on January 1, 2012.
Health New England remains committed to working with our trading partners still utilizing 4010 standards to support the migration from HIPAA 4010 to HIPAA 5010.
To help make this transition as smooth as possible, we have designated a contact person for each transaction type. If you have any questions or identify any issues as you go about your testing, please contact us at hipaa5010@hne.com.
Clearinghouses
270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide
276/277 Health Care Claim Status Request and Response Companion Guide
834 Benefit Enrollment and Maintenance Companion Guide
835 Claims Payment Advice Companion Guide
837 Claims Companion Guide
Health New England is partnering with Healthmap Solutions to provide more comprehensive care for our members (all plan types) with Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD). Healthmap’s KHM program integrates into your existing practice workflow to reduce additional office work, while enhancing communication. Healthmap offers the best kidney health solution that will support you in providing care for your patients.
All of our members identified as being at risk for CKD stage 3 and higher are included in the KHM program. Healthmap will contact you to schedule an overview of the program and to collaborate as you manage your patients with CKD and ESRD.
Individualized patient recommendations are addressed in two ways to achieve best outcomes:
The Care Navigation team provides complex care coordination services to support health care needs between office visits. Care Navigation supports the patient’s overall care and focuses on identifying and removing barriers that prevent a patient from achieving their optimal health.
Learn more at healthmapsolutions.com. For additional information, review this Healthmap Provider Packet or call Healthmap at (800) 481-0474 (tty: 711) to schedule an orientation or to refer patients.
As a result of the Covid-19 Pandemic, a growing number of individuals and families across Massachusetts are facing food insecurity, many for the first time. Masshealth, in partnership with other state agencies and food non-profit organizations, has developed a simple guide that your member-facing staff or your network providers can use to help identify Masshealth members who need food assistance and connect them to resources in the community. Those food assistance resources can provide your members with immediate access to food, as well as recurring financial support for the purchase of food.
English version
Spanish version
Adapting Your Practice: Treatment And Recommendations For Homeless Patients
Adult Preventative Guidelines
ADHD Clinical Guidelines
ADHD: Clinical Practice Guideline For The Diagnosis, Evaluation, And Treatment Of Attention-Deficit/Hyper Activity Disorder In Children And Adolescents.
ADHD:&Nbsp; Diagnosis And Management Of Adhd In Children, Young People And Adults.
ADHD AHRQ Guidelines
ADHD ACPA Guidelines
AHA/ACCF Secondary Prevention & Risk Reduction Therapy For Patients W/ Coronary & Other Atherosclerotic Vascular Disease
AHA/ACC Guideline Update For Management Of Patients W/ Unstable Angina & Non-St-Elevation Acute Coronary Syndromes
Asthma
Blood Lead Screening Of Medicaid Eligible Children Aged 1-5 Years:&Nbsp; And Updated Approach To Targeting A Group At High Risk
Coronary Artery Disease (CAD)
Cholesterol Management Guidelines
Chronic Obstructive Pulmonary Disease (COPD)
Clinical Trials Availability And Qualifications
Congestive Heart Failure
Depression Clinical Guidelines Effective 3/8/2018
diabetes guidelines
diagnosis and management of asthma
hypertension guidelines
Immunization Schedule For Persons Aged 0 Through 6 Years
Pediatric Preventative Guidelines
Neuropsych Testing
Addendum To Neuropsychological Testing
Perinatal Care Guidelines
Guideline For Treatment For SA Disorders
Treatment Of SA - APA Guidelines
Treament For SA - ASAM Practice Guidelines
anesthesia services
audit program
autism professional services
bilateral and multiple professional and facility services
claims editing
counseling and/or risk factor reduction intervention servicesnew effective 1/1/2021
discarded drugs and biologicals
diabetic care
drug testing
emergency department services
evaluation and management
genetic testing
ground transportation services - archived
hospice services
immediate post-concussion assessment and cognitive testing (impact) testing
individual consideration services (applies to medicaid only)
inpatient hospital services
laboratory professsional services new effective 9/1/20
mammography services
mid-level practitioners
modifier new effective 9/1/20
newborn and neonatal care
non-covered, experimental & investigational services
non reimbursed revenue codes
neuropsychological and psychological testing
nutritional counseling
observation services
obstetrical care
preventive services
provider based billing
readmission to inpatient level of care
serious reportable events / provider preventable conditions
Skilled Home Health Care
Skilled Nursing Facility
sleep studies
telehealth (telemedicine) services
transportation services
treatment room
unlisted procedures
urgent, extended care & walk-in care
urine drug testing - archived
vaccines and immunizations
Health New England is excited to announce a new, cutting-edge pharmacy transparency service called Rx Savings Solutions. This new service partner helps patients/members find the lowest-cost prescription drug, according to their own health plan. It empowers both providers and patients with the information needed to select the most cost-effective, yet therapeutically-conscious, prescription medication for the patient. The patented software analyzes prescription claims and considers all possible clinical options to save its users money on prescriptions, all within the user’s specific plan design.
Rx Savings Solutions may reach out to providers on behalf of our commercial members by fax. See sample fax pdf below for reference.
Provider FAQ
Sample RxSS Fax Form
When a Health New England member needs rehabilitation services for a serious or persistent health issue or skilled therapy, a skilled nursing facility (SNF) can provide short-term care. This booklet will help guide the skilled nursing facility through Health New England’s process to ensure a smooth transition for our member.
Requirements and Guidelines: Reference Guide for Skilled Nursing and Rehabilitation Facilities to learn more about clinical criteria, admission, initial & concurrent reviews, discharge, guidelines on product lines and more. In addition, reference our Skilled Nursing Payment Policy for more information on payment guidelines.
Skilled Nursing and Rehabilitation Facilities Guide
Skilled Nursing Payment Policy