Find A Provider

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

Autologous Chondrocyte Transplant Revised Effective 6/1/20

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 Revised Effective 6/1/20

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

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 New - Effective 7/1/20

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 Revised Effective 4/1/20

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

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 New Effective 11/13/19

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 Revised Effective 6/1/20

Positive Airway Pressure Archived Effective 4/4/17

Preimplanataion Genetic Diagnosis (PDG) Revised Effective 6/1/20

Proton Beam Therapy Revised Effective 9/1/20

Radiofrequency Ablation Revised Effective 6/1/20

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 Revised Effective 6/1/20

Spinal Cord Stimulation Revised Effective 6/1/20

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 Revised Effective 12/1/20

Surgical Treatment of Gynecomastia Revised Effective 4/1/20

Therapeutic Shoes and Orthotics Revised Effective 12/1/20

Total Ankle Replacement Revised Effective 9/1/20

Total Hip Resurfacing Archived 6/9/20

Transplants and Ventricular Assist Devices New Effective 6/12/2019

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

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

Prior Authorization
To obtain a prior authorization, log on to the  eviCore portal. A username and password is required. When checking on a status or denial of an authorization, you may call eviCore at (888) 693-3211.

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: 

• 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

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

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

• 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:

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.

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.

Provider FAQ

Sample RxSS Fax Form