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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)

Health New England is partnering with Vital Decisions, a company specializing in providing services to individuals and their families who are experiencing advanced illness. This partnership allows access to Vital Decisions’ Living Well Program.

Vital Decisions’ specially trained professionals will work with our Fully Funded Commercial, Medicare and BeHealthy Partnership® members who are experiencing difficult healthcare situations. The Vital Decisions’ team members work, through a series of telephone or video sessions, to help educate, discuss, and work through the important topics of advance care and life planning. Their role is to help individuals identify their quality of life preferences and values and help them to actively and effectively communicate their priorities to family and physicians. This will help to ensure that more effective shared decision-making processes occur and will help to align decisions with the individual’s preferences and priorities.

Vital Decisions’ staff will at no time interfere with the physician-patient relationship, provide medical advice, or provide an opinion regarding the care plan or team in place. Experience has demonstrated that the program enhances communication and the overall patient-physician relationship.

• Physician FAQs
• Detailed Descriptions for Physicians

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:*

• Acupuncture
• Massage Reimbursement
• Chiropractic
• Physical Therapy
• Occupational Therapy
• Cognitive Behavioral Therapy (no benefit limit)
• Nutritional Counseling (4 preventive visits)
• Osteopathic Manipulative Medicine
• Interventional Pain Management: Nerve Block, spine surgery, transcutaneous electrical nerve stimulation (TENS) unit

*Coverage and/or number of visits may vary depending on plan type.

• Abdominal panniculectomy  Revised effective 12/1/21
• Ambulatory electrocardiography  Revised effective 8/1/21
• Ambulatory Electrocardiography Revised effective 8/1/2022
  
• Antibody testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2)  Revised effective 2/1/22
• Artificial intervertebral cervical disc  Revised effective 2/1/22
• Azedra New effective 12/1/21
• Balloon sinus dilation of the Eustachian tubes  Revised effective 8/1/21
• Balloon Dilation of the Eustachian Tubes Revised effective 8/1/2022
• Bone grafts for spinal defects  Revised effective 8/1/21
• Bone Grafts for Spinal Disorders Revised effective 8/1/2022
  
• BH ABA for autism spectrum disorders  Revised effective 11/17/21
• BH admission and CSS  Revised effective 11/4/21
• BH CBAT  Revised effective 11/4/21
• BH CSU  Revised effective 11/4/21
• BH day treatment Revised effective 5/5/22
• BH FST  Revised effective 11/4/21
• BH inpatient admissions and concurrent review for substance abuse disorder Revised effective 5/5/22
• BH neuropsychological testing  Revised effective 5/5/22
• BH transcranial magnetic stimulation  Revised effective 11/4/21
• Biofeedback for urinary and fecal incontinence  Archived 5/10/22
• Blepharoplasty and browplasty  Revised effective 6/1/21
• Blepharoplasty and browplasty  Revised effective 6/1/22
• Bronchial thermoplasty  Revised effective 2/1/22
• Centers for Medicare & Medicaid (cms) and MassHealth criteria and guidelines  Revised effective 6/17/21
• Chimeric antigen receptor T-cell therapy (CAR-T cell therapy)  Revised effective 2/1/22
• Chimeric antigen receptor T-cell Therapy (CAR-T cell therapy) Effective 6/1/22
• Clinical trials  Revised effective 8/1/21
• Clinical Trials Revised effective 8/1/2022
• Clinical trials - Medicare  Revised effective 8/1/21
• Clinical Trials - Medicare Revised effective 8/1/2022
  
• Clinical review criteria for short acting opioids
• Cochlear implants and BAHA (bone anchored hearing aid)  Revised effective 12/1/21
• Contact lenses (formerly scleral lens) Effective 12/1/21
• Contact lenses Effective 6/1/22
• Corneal cross linking  Revised effective 2/1/2022
• Deep brain stimulation treatment  Revised effective 12/1/21
• Drug testing  Revised effective 2/1/22
• Endothelial keratoplasty  Revised effective 12/1/21
• Endovenous ablation therapy for varicose veins  Revised effective 6/1/21
• Endovenous ablation therapy for varicose veins  Revised effective 6/1/22
• Female breast reduction (formerly reduction mammoplasty) Effective 4/1/22
• Formula and enteral nutrition  Revised effective 8/1/21
• Formula and enteral nutrition Effective 6/1/22
  
• Gait trainers (MassHealth) Effective 4/1/18
• Gardasil protocol-hpv vaccine
• Gastric electrical stimulation  Revised effective 2/1/22
• Gender reassignment surgery  Revised effective 8/1/21
• Gender Affirming Surgery Revised effective 8/1/2022
  
• Home health aide- ADL only  Revised effective 8/1/21
• Home Health Aide - ADL only Revised effective 8/1/2022
  
• Home health care services - Medicaid  Revised effective 2/1/22
• Hospital beds (MassHealth) Effective 4/1/18
• Hydrogen breath testing  Revised effective 12/1/21
• Hyopbaric oxygen (HBO) therapyRevised effective 4/1/22
• Intacs corneal implants  Revised effective 12/1/21
• Infertility protocol  Revised effective 9/1/21
• Knee braces  Revised effective 9/1/21
• Laser-assisted uvulopalatoplasty or uvulopalatopharyngoplasty  Revised effective 6/8/21
• Lutetium LU 177 Dotatate, therapeutic  Revised effective 2/1/22
• Medical necessity  Revised effective 7/1/21
• Nodify lung nodule risk assessment  Revised effective 12/1/21
• Non-covered, experimental and investigational services  Revised effective 2/1/2022
• Orthognathic surgery  Revised effective 8/1/21
• Orthognathic Surgery Revised effective 8/1/2022
• Outpatient physical therapy and occupational therapy  Revised effective 2/1/2022
• PANS/PANDAS NEW Effective 6/1/22
• Percutaneous left atrial appendage closure  Revised effective 12/1/21
• Photochemotherapy, phototherapy, laser treatments  Revised effective 6/1/21
• Photochemotherapy, phototherapy, laser treatments  Revised effective 6/1/22
• Preimplantation genetic diagnosis (PDG) Revised effective 6/1/21
• Preimplantation genetic diagnosis (PDG) Revised effective 6/1/22
• Proton beam therapy  Revised effective 9/1/2021
• Radiofrequency ablation  Revised effective 6/1/21
• Radiofrequency ablation  Revised effective 6/1/22
• Reconstructive breast surgery  Revised effective 9/1/21
• Reconstructive repair of pectus excavatum or pectus carinatum  Revised effective 8/1/2021
• Reconstructive Repair of Pectus Excavatum or Pectus Carinatum Revised effective 8/1/2022
• Rhinoplasty  Revised effective 8/1/21
• Rhinoplasty Revised effective 8/1/2022
• Sacral nerve and electrical percutaneous tibial nerve stimulation  Revised effective 2/1/22
• Sacroiliac joint fusion  Revised effective 9/1/21
• Sacroiliac joint fusion  Revised effective 6/1/22
• Skin and soft tissue substitutes  Revised effective 2/1/22
• Speech therapy  Revised effective 9/1/21
• Speech therapy Revised effective 8/1/2022
  
• Speech therapy for autism disorders  Revised effective 4/1/21
• Speech therapy for autism disorders  Revised effective 6/1/22
• Spinal cord stimulation  Revised effective 6/1/21
• Spinal cord stimulation  Revised effective 6/1/22
• Surgical management of morbid obesity  Revised effective 12/1/21
• Surgical treatment of gynecomastia  Revised effective 4/1/22
• Therapeutic shoe and orthotic coverage  Revised effective 8/1/21
• Therapeutic shoe and orthotic coverage Effective 6/1/22
  
• Total ankle replacement  Revised effective 9/1/21
• Transanal endoscopic microsurgery (TEMS) New Effective 4/1/21
• Transplants and ventricular assist devices Revised effective 9/1/21
• Treatment of lipodystrophy syndrome (LDS) Revised effective 12/1/21
• Tumor treatment fields (TTFS) (i.e., optune device)  Revised effective 12/1/21
• Upper airway stimulation device (UAS) / hypoglossal nerve stimulation (HGNS) (Inspire)  Revised effective 9/1/21
• Water vapor thermal therapy (Rezum)  Effective 6/8/21

Evicore Healthcare, LLC, a national leader in integrated, innovative intelligent care management solutions, partners with Health New England in the management of authorizations and reporting for all our business lines.

The services they provide are: 

• High cost imaging 
• Sleep study program 
• Genetic testing 

For more information about evicore, please go to  www.evicore.com

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: 

• Prior authorization 
• Claims processing and adjudication 
• Member and provider services 
• Data reporting 
• Provider contracting, credentialing and management 
• Provider inquiries, grievances and appeals 

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 HIPAA5010 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 HIPAA4010 to HIPAA5010.

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.

• Clearing Houses 
• 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 5010 Claims Companion Guide

An Interactive Voice Response (IVR) is an automated phone system technology that allows for incoming
callers to access information by a voice response system of pre-recorded messages. Health New
England’s system will help our providers 24 hours, 7 days a week. If our system is unable to provide you
with the information you need, it will direct you to a live Claims Representative during our normal
business hours 8 a.m. – 5 p.m., Monday – Friday.

For additional assistance on using the system, please see the Frequently Asked Questions document below.

FAQ - Claim Status

FAQ - Eligibility

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 Kidney Health Management (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:

• Identification of patient opportunities/care-gaps related to medications, lab testing, specialty referrals and selective quality metrics
• Clinical support for you and your patients who may benefit from more personalized support based on disease intensity through HealthMap’s care navigation

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 the Health New England dedicated line at (800) 985-9208 to schedule an orientation or to refer patients.

Beginning January 1, 2022, Health New England will initiate a site of service program review as part of our prior authorization process for a select group of medications. Health New England members between the ages of 18 and 64 will be required to shift their care from an outpatient hospital setting to home infusion. This change is to ensure Health New England members receive appropriate and safe administration of infusion medications in the most cost-effective location. Health New England patients receiving infusions in the physician’s office will not be affected by this policy.

• Magellan FAQs
• Magellan SOS policy

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: Dlinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyper activity disorder in children and adolescents
• ADHD: Diagnosis and management of adhd in children, young people and adults
• ADHD: AHRG 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:  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
• Neuropsych testing
• Addendum to neuropsychological testing
• Pediatric preventative guidelines
• Perinatal care guidelines
• Guideline for treatment for SA disorders
• Treatment of SA - APA guidelines
• Treament for SA - ASAM practice guidelines

ProgenyHealth, a national company dedicated to population health management for infants admitted to the neonatal intensive care unit (NICU) or special care nursery (SCN), Partners with Health New England on the care management and utilization management for medically complex newborns in our commercial and Medicaid business lines. their care coordination team includes neonatologists, pediatricians, nurses, and social workers. this team has a deep understanding of the evidence-based protocol needed to support outcomes and supports families from initial NICU or SCN admission to first year of life.  

 The services they will provide are as follows: 

• Utilization review 
• Medical management services 

Prior authorizations/coverage:  

The prior authorization comes into Health New England as it does today. ProgenyHealth will then follow the infant from initial admission into the NICU (for our commercial member or effective date added to BeHealthy Partnership) or SCN until the first year of life*. Health New England resumes care management/utilization management after the first year of life. 

*ProgenyHealth will follow any readmissions through the 1st year of life for level of care.  

For additional information on ProgenyHealth, please visit https://www.progenyhealth.com

ProgenyHealth FAQ

The Federal No Surprises Act protects Health New England members from receiving surprise medical bills from providers who are not contracted with Health New England, otherwise known as out-of-network providers. This Act includes requirements associated with transparency of health care cost, more timely validation of provider directory information, and updating member ID cards to include more benefit information.

Beginning 1/1/2022:

• A provider needs to disclose participation with Health New England upon scheduling an appointment and provide information about who is performing the service and anticipated costs.
• A provider must follow the “notice and consent” process. Prior to performing certain services, the provider needs to inform our member of their rights not to be balanced bill and obtain the member’s consent in writing.
• A provider, if they choose to terminate their contract with Health New England, can continue treating our member up to 90 days after they terminate as long as it falls within the following criteria:
  • A course of treatment for aserious or complex condition
  • Undergoing institutional or inpatientcare
  • Scheduled to undergo non-electivesurgery (including post-operative care)
  • Pregnant and undergoing treatment
  • Terminally ill and receiving treatment
• A provider, not contracted with Health New England, providing emergency care to our member, will follow utilization management criteria as if in-network. In-network cost sharing will apply and will count towards in-network deductible and out-of-pocket maximum, if applicable to the member’s benefit plan.
• A provider, who is not contracted with Health New England and provides non-emergency services to our member in a facility contracted with us, those services will be covered at in-network cost share (deductible/coinsurance) and count towards the member’s in-network deductible and out-of-pocket maximum, if applicable to the member’s benefit plan.
• Health New England will follow the guidelines established by the Federal No Surprises Act as it relates to reimbursing with a qualified payment amount (QPA), addressing provider appeals within 30 days and, if applicable, following independent dispute resolution (IDR) process.
• Health New England distributed new Member ID cards to our Fully Funded and Self-Funded Commercial Members displaying the required information stated within this Act.

In addition, our network providers are required to validate the accuracy of our Provider Directory every 90 days. To learn more about provider data, please go to our Provider Manual at https://healthnewengland.org/provider-manual, click “Network Operations” and reference “Administrative Procedures.”

These guidelines establish when Health New England (HNE) must accept non-contract provider appeals. Non-contract providers are providers that are not participating in the HNE Medicare Advantage product but who have provided services to a Health New England Medicare Advantage member. If HNE Medicare Advantage denies a request for payment, in whole or in part, from a non-contract provider, HNE Medicare Advantage shall notify the non-contract provider of the specific reason for the denial and shall provide a description of the appeals process.

When a non-contract provider submits an appeal of a denial of payment, HNE Medicare Advantage must verify the following information prior to processing the appeal:

• Was the appeal submitted within 60 days of receipt of the explanation of payment notice?
• Was the appeal accompanied by a completed waiver of liability statement (wls)?
• If the appeal was submitted after 60 days, according to Medicare guidelines*, the appeal is not eligible for consideration and should be dismissed. In this instance, the non-contract provider will receive written notice of the dismissal from HNE Medicare advantage but may request further review by the independent review entity listed below:

Maximus Federal Services, Inc.

Medicare Managed Care & Pace Reconsideration Project

3750 Monroe Avenue, Suite 702

Pittsford, NY 14534-1302

Fax: 585.425.5292

• If the appeal was submitted within 60 days, the appeal must also be accompanied by a WLS by which the non-contract provider agrees to hold the member harmless even in the event the health plan denies the appeal.
• If the WLS is not received with the appeal, HNE Medicare Advantage will notify the non-contract provider of the missing WLS in writing.
• The non-contract provider is still obligated to submit the WLS within the original 60 days from the date they received the explanation of payment notice, not 60 days from receiving the notice indicating a WLS is still needed to process the appeal.
• if the WLS is received within the 60 day timeframe, then HNE Medicare Advantage will process the appeal and notify the non-contract provider of the outcome. In the event the WLS is either not received or not received within the specified timeframe, the non-contract provider will receive written notice of the dismissal from HNR Medicare Advantage but may request further review by the independent review entity listed below:

Maximus Federal Services, Inc.

Medicare Managed Care & Pace Reconsideration Project

3750 Monroe Avenue, Suite 702

Pittsford, NY 14534-1302

1  See the Medicare Managed Care Manual , Chapter 13, “Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPS), (collectively referred to as Medicare health plans),” Sections 40.2.3 and 60.1.1.

• Anesthesia services
• Audit program
• Autism professional services
• Bilateral and multiple professional and facility services
• Claims editing
• Counseling and/or risk factor reduction intervention services
• COVID-19 vaccination
• Discarded drugs and biologicals
• Diabetic care
• Drug testing
• Emergency department services
• Evaluation and management
• Genetic testing
• Hospice services
• Immediate post-concussion assessment and cognitive testing (impact) testing
• Individual consideration services (applies to Medicaid only) 
• Inpatient hospital services
• Laboratory professional 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
• 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.

Questions: please reach out to the Rx Savings Solutions pharmacy support team at (800) 268-4476 or email support@rxsavingssolutions.com, Monday-Friday, from 8 a.m. to 9 p.m. ET. For additional information, visit www.healthnewengland.org/rxss.

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