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Effective October 1, 2018, 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. 

• 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,1 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:

• If the appeal was submitted within the 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 is 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 HNE Medicare Advantage but may request further review by the Independent Review Entity listed below:

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.