Program Overview

The Centers for Medicare and Medicaid Services (CMS) Acute Hospital Care at Home program helps to increase hospital capacity and improve resource allocation during the COVID-19 national public health emergency. This is an expansion of the Hospital Without Walls program. The Hospital Without Walls program allowed hospitals to provide services in locations beyond existing facilities.

In November 2020 and as part of Acute Hospital Care at Home, CMS waived a previous Medicare Conditions of Participation requirement. This waiver allows qualifying hospitals to receive inpatient payment for providing acute-level services to Medicare beneficiaries in their homes.

CMS Waiver Process

CMS is accepting waiver requests to waive §482.23(b) and (b)(1) of the Hospital Conditions of Participation, requiring nursing services to be provided on-premises 24 hours a day, 7 days a week, and the immediate availability of a registered nurse (RN) for care of any patient. Here are the guidelines on the waiver criteria and process.

CMS divides the waiver requests into 2 categories based on a hospital’s prior experience:

• Hospitals that have previously provided home acute hospital services to 25+ patients
• Hospitals that have either provided care to less than 25 patients, or not provided home acute hospital services at all

As of July 27, 2022 CMS has approved 245 hospitals and 110 health systems in 36 states to participate in the Acute Hospital Care at Home program. Refer to the complete list of approved hospitals and health systems to learn more.

Please note: Every hospital certified to provide care to Medicare patients has a unique CMS Certification Number (CCN). Any hospital seeking to provide Acute Hospital Care at Home must submit the waiver request under its unique certification number. For example, if a hospital system includes 10 hospitals, but only 4 of those hospitals admit patients who use Acute Hospital Care at Home services, 4 separate waiver requests must be submitted.

Qualifying Claim / Billing Requirements

Health New England requirements:
Health New England will accept qualifying¹ claims for the approved plans until further notice or through the duration of the national public health emergency. Health New England will deny any claims received for Plans not approved under this program.

Approved Plan(s) for the CMS Acute Hospital Care at Home Program.

• Medicare Advantage

Not approved Plan(s) for the CMS Acute Hospital Care at Home Program:

Health New England Claim Requirements:

When submitting claims to Health New England, please use the following guidelines:

• Occurrence Span Code 82
  • Title: Hospital at Home (span code 82 care dates)
  • Definition: The from/through dates of a period of hospital at home care provided during an inpatient hospital stay
• Revenue Code 0161
  • Subcategory Definition: Room & Board – Hospital at Home
  • Standard Abbreviation: R&B/Hospital at Home

CMS requirements:
To meet the standards of a qualifying Medicare Advantage claim for the Acute Hospital Care at Home program, facilities must complete the waiver process and have received the waiver from CMS.

¹A qualifying claim requires CMS waiver requirements to be met, along with the following criteria:

• Evidence-based criteria for inpatient care.
• Notification (Prior Approval) with Health New England’s Utilization Management team under our Clinical Services Department.
  • Notify us immediately when:
    • An applicable member is admitted to the Acute Hospital Care at Home program
    • A member in the program is transferred back to inpatient care facility or has any other status change in their care plan
      • Notification can be made by sending a fax to 413-233-2700.
    • For our HMO members only pre-approved or urgent admits are allowed Out of Network.

Additional Notes:

• All Acute Hospital Care at Home claims are subject to the Health New England’s standard Prior Authorization process.
• Observation stays are not eligible for Acute Hospital Care at Home and will not be reimbursed.
• Payment for Acute Hospital Care at Home claims will be handled in accordance with terms in the health care professional’s Participation Agreement with Health New England.
• For any claim denial received, the network (contracted) providers may not bill the member for any Acute Hospital Care at Home-related charges. If you disagree with the claim denial, you may ask Health New England to review the denial using the reconsideration and appeal process outlined in our provider manual.
• We’ll continue to update billing guidance on this page as necessary and will alert health care professionals when updates are made.  

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:*

• 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 4/1/23
• Ambulatory cardiac monitoring Effective 6/1/23
• Ambulatory cardiac monitoring Revised effective 1/1/24
• Antibody testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) Retired effective 1/1/24
• Artificial intervertebral cervical disc Revised effective 2/1/23
• Autologous Chondrocyte Implantation or Transplantation Revised effective 9/1/23
• Azedra Revised Effective 12/1/22
• Balloon Dilation of the Eustachian Tubes Revised effective 6/1/23
• Bariatric surgery Revised effective 8/1/23
• BH ABA for autism spectrum disorders  Revised effective 1/5/23
• BH admission for concurrent review ASAM 3.5  Revised effective 11/3/22
• BH CBAT Revised effective 6/1/23
• BH CSU  Revised effective 11/3/22
• BH day treatment Revised effective 5/5/22
• BH FST  Revised effective 11/3/22
• BH inpatient admissions and concurrent review for substance abuse disorder Revised effective 10/1/23
• BH Masters Level and Licensed Outpatient Therapists Revised effective 1/5/23
• BH neuropsychological testing  Revised effective 5/5/22
• BH transcranial magnetic stimulation  Revised effective 11/3/22
• Blepharoplasty and browplasty Revised effective 5/1/23
• Bone grafts for spinal defects Revised effective 9/1/23
• Bone grafts for spinal defects Revised effective 11/1/23
• Breast Surgery New effective 11/1/23
• Bronchial thermoplasty Revised effective 2/1/23
• Cardiac monitoring, ambulatory 
  
  • See Ambulatory Cardiac Monitoring
• CardioMEMS New; Effective 9/1/22
  • See Insertion of Wireless Pulmonary Artery Pressure Sensor & Monitoring (i.e.,CardioMEMS)
• Chimeric antigen receptor T-cell Therapy (CAR-T cell therapy) Revised effective 2/1/23
• Clinical Trials Revised effective 7/1/23
• Cochlear Implants Revised effective 7/1/23
• Contact Lenses Effective 12/1/22
• Corneal cross linking Revised effective 2/1/23
• Cosmetic and reconstructive procedures New effective 11/1/23
• Deep Brain Stimulation Treatment 
  • See Deep Brain and Cortical Stimulation
• Deep Brain and Cortical Stimulation Revised effective 1/1/24
• Dental Anesthesia Effective 6/1/23
• Dental Anesthesia and Procedures Revised effective 1/1/24
  
• Drug testing Revised effective 2/1/23
• Drug testing Revised effective 10/1/23
• Endothelial Keratoplasty Retired effective 1/1/24
• Endovenous Ablation Therapy for Varicose Veins Retired effective 11/1/23
  • See Venous insufficiency and varicose veins treatment
• Female breast reduction Retired effective 11/1/23
  • See Breast Surgery
• Gastric electrical stimulation Revised effective 2/1/23
• Gender affirming services Revised effective 11/1/23
• High intensity focused ultrasound (HIFU) for prostate cancer Effective 9/1/22
• Home Health Aide - ADL only Retired effective 8/1/23
  • Home health aide - ADL only - see Home Health Care Services
• Home health care services Revised effective 8/1/23
• Hydrogen Breath Testing Revised Effective 12/1/22
• Hyperbaric oxygen (HBO) therapy Revised effective 4/1/23
• Insertion of Wireless Pulmonary Artery Pressure Sensor & Monitoring (i.e., CardioMEMS) Revised effective 9/1/23
• Insertion of Wireless Pulmonary Artery Pressure Sensor & Monitoring (i.e., CardioMEMS) Revised effective 11/1/23
• Intacs Corneal Implants Revised Effective 12/1/22
• Infertility Protocol Revised Effective 12/1/22
• Knee braces Retired Effective11/1/23
  • Knee braces - please refer to DME section forNorthwood Criteria
• Laser-assisted uvulopalatoplasty or uvulopalatopharyngoplasty  Effective 9/1/22
• Lutetium LU 177 Dotatate - therapeutic Revised effective 2/1/23
• Lymphedema - Surgical Treatment New effective 10/1/23
  
• Medical necessity 
  • See Medical Necessity and Experimental and Investigational
• Medical Necessity and Experimental and Investigational Revised effective 1/1/24
• Nodify Lung Nodule Risk Assessment Retired effective 12/1/23
• Non-covered, experimental and investigational services Retired effective 1/1/24
  • Please refer to Medical Necessity 
• Nutritional Counseling for Eating Disorders New Effective 4/1/23
• Orthognathic Surgery Revised effective 6/1/23
• Outpatient physical therapy and occupational therapy Revised effective 2/1/23
• PANS/PANDAS Revised effective 4/1/23
• Percutaneous Left Atrial Appendage Closure Revised effective 12/1/22
• Peripherally implanted nerve stimulation 
  • See Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS)
• Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS) Effective 1/1/24
• Peroral Endoscopic Myotomy (POEM) New effective 12/1/22
  
• Photochemotherapy (PUVA) - phototherapy, laser treatments Revised effective 10/1/23
• Preimplantation genetic testing Revised effective 5/1/23
• Proton beam therapy Revised effective 10/1/23
• Radiofrequency ablation Effective 9/1/22
• Radiofrequency ablation for spinal pain - Update effective 12/1/23
  • Was previously radiofrequency ablation
• Reconstructive breast surgery Retired effective 11/1/23
  • See Breast Surgery
• Reconstructive Repair of Pectus Excavatum or Pectus Carinatum Revised effective 6/1/23
• Rhinoplasty Revised effective 6/1/23
• Sacral nerve and electrical percutaneous tibial nerve stimulation Revised effective 2/1/23
• Sacroiliac joint fusion Revised effective 7/1/23
• Skin and soft tissue substitutes Revised effective 2/1/23
• Sleep Disordered Breathing Diagnosis New effective 10/1/23
• Speech Language Pathology (SLP) Services Revised Effective 11/1/23
  
• Speech therapy Revised effective 8/1/2022
  
  • See Speech Languages Pathology (SLP) Services
• Speech therapy for autism disorders Revised effective 6/1/23
• Spinal cord stimulation
  • See Spinal Cord and Dorsal Root Ganglion Stimulation
• Spinal Cord and Dorsal Root Ganglion Stimulation Effective 1/1/24
• Surgical management of morbid obesity 
  • Surgical management of morbid obesity - See Bariatric surgery
• Surgical treatment of gynecomastia Retired effective 11/1/23
  • See Breast Surgery
• Total ankle replacement Effective 9/1/22
• Total ankle replacement Revised effective 12/1/23
• Transanal endoscopic microsurgery Effective 4/1/23
• Transplants and ventricular assist devices Revised effective 9/1/22
• Transurethral water jet ablation Revised effective 2/1/23
• Treatment of Lipodystrophy Syndrome (LDS) Revised effective 12/1/22
• Tumor Treatment Fields (TTFS) (i.e., Optune Device) Revised effective 12/1/22
• Upper airway stimulation device (UAS) / hypoglossal nerve stimulation (HGNS) (Inspire)  Revised effective 9/1/22
• Venous insufficiency and varicose veins Revised effective 11/1/23
  
• Water vapor thermal therapy (Rezum)  Effective 9/1/22

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

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

The below chart provides guidance on when services received an approved authorization from eviCore and when it is recommended for those services to be rendered:

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 and those exceptions where Health New England will review your request. In both situations, Northwood’s criteria is used to review for medical necessity. Please reference the medical policies below for each product line. For authorization forms, please go to Northwood’s website and follow the link. For those exceptions where Health New England will help, please go to https://healthnewengland.org/forms and click “Clinical Request Forms.” For additional information such as Northwood’s provider manual for Health New England, frequently asked questions or provider orientation, please visit Northwood's website. 

Provider types managed by Northwood vs. Health New England 

Northwood managed codes (effective 7/1/23)

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

What is Health Equity?

“Health Equity is the opportunity for everyone to attain their full health potential. No one is disadvantaged from achieving this potential because of their social position (e.g., class, socioeconomic status) or socially assigned circumstance (e.g., race, gender identity/gender expression, ethnicity, disability status, religion, sexual orientation, geography, language, etc.).” – MassHealth Definition

What is CLAS?

“Culturally and linguistically appropriate services (CLAS) is a way to improve the quality of services provided to all individuals, which will ultimately help reduce health disparities and achieve health equity. CLAS is about respect and responsiveness: Respect the whole individual and Respond to the individual’s health needs and preferences.

Health inequities in our nation are well documented. Providing CLAS is one strategy to help eliminate health inequities. By tailoring services to an individual's culture and language preferences, health professionals can help bring about positive health outcomes for diverse populations.

The provision of health services that are respectful of and responsive to the health beliefs, practices, and needs of diverse patients can help close the gap in health outcomes. The pursuit of health equity must remain at the forefront of our efforts; we must always remember that dignity and quality of care are rights of all and not the privileges of a few.” – HHS Excerpt.

For more information on CLAS Standards click on the link HHS National Class Standards

Our Community

The mission of Health New England is to improve the health and lives of the people in its communities, and it is deeply committed to the individuals it serves every day.

Below is a representation of HNE’s population linguistic needs using five-year estimated Census data from the 2020 Census. This data clearly shows the only two languages that meet the critical 5% threshold are English (81.2%) and Spanish (11.63%). The only county where this threshold is maintained by itself is Hampden County.

For the most recent Community Health Needs Assessment and to learn more about our members follow the link below.

2022 HNE Community Health Needs Assessment

Providing appropriate linguistic services

What is your responsibility?

Health New England providers have a contractual requirement to provide translation services at the request of HNE members.

How Health New England can Help

In the event your existing translation resources are unavailable, you may utilize HNE’s emergency OnDemand translation services. For more information, please call Provider Relations at (800) 842-4464, extension 5000, or send an email to providerrelations@hne.com.

Other available resources

For more information on interpreter services available to you, follow the link below. https://www.mass.gov/info-details/interpreter-service

Offering I Speak Cards is one way to ensure patient’s linguistic needs are being correctly identified and appropriate resources/support is provided. Access to these resources in English, Spanish and many other languages may be found I SPEAK Cards (ct.gov)

Want to learn more?

Did you know? HHS offers a 9 credit hour CLAS training for medical providers? Check the link and sign up today! Think Cultural Health CME Training

The Agency for Healthcare Research and Quality offers professional education and training including, Improving Patient Safety Systems for Patients With Limited English Proficiency. https://www.ahrq.gov/health-literacy/professional-training/lepguide/index.html

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 Medicare members 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.

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.
  • Where to send appeals for negotiation: send the “Open Negotiation Form” from CMS.gov and any supporting documentation including the claim number, explanation of dispute, and reference of QPA/No Surprise Act.  The provider may either:
    Mail to:  Health New England, Attention: Provider Appeals Department, One Monarch Place, Suite 1500, Springfield, MA 01144 or,
    
    Fax to: 413-233-2797 
  • Where to send information once a provider engages in the IDR process: please send any and all notifications to our Provider Contracting Department at provconqpa@hne.com
• 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
• Routine supplies and equipment
• Serious reportable events / provider preventable conditions
• Skilled home health care
• Skilled nursing facility
• Sleep studies
• Telehealth (telemedicine) services
• Timely filing
• Transportation services
• Treatment room
• Unlisted procedures
• Urgent, extended care & walk-in care
• Vaccines and immunizations

These policies apply to all in-network and out-of-network¹ providers requesting to have Health New England (HNE) review their original claim denial and ask for reconsideration.

• Contract Rate, Payment Policy or Clinical Policy Claim Denials
• Notification of Prior Authorization Claim Denial
• Request to Review Duplicate Claim Denials
• Claim Past Filing Time Limit Denial

¹Health New England follows, outside of these policies, the guidelines and regulations of The Federal No Surprise Act, if applicable to the claims payment.

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