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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
Abdominal Panniculectomy Revised Effective 12/1/21
Ambulatory Electrocardiography Revised Effective 8/1/2021
Antibody Testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) New Effective 2/1/21
Afirma Thyroid FNA Analysis Testing Archived Effective 6/12/18
Artificial Intervertebral Cervical Disc Revised Effective 2/1/21
Azedra New Effective 12/1/20
Balloon Sinus Dilation of the Eustachian Tubes Revised Effective 8/1/2021
Bone Grafts for Spinal Defects Revised Effective 8/1/2021
BH ABA for Autism Spectrum Disorders Revised Effective 5/6/2021
BH Admission and CSS Revised Effective 11/5/20
BH CBAT Revised Effective 11/5/20
BH CSU Revised Effective 11/5/20
BH Day Treatment Revised Effective 5/6/2021
BH FST Revised Effective 11/5/20
BH Inpatient Admissions and Concurrent Review for Substance Abuse Disorder Revised Effective 5/6/2021
BH Neuropsychological Testing Revised Effective 5/6/2021
BH Psych Testing
BH Transcranial Magnetic Stimulation Revised Effective 2/1/21
Biofeedback for Urinary and Fecal Incontinence Revised Effective 8/1/2021
Blepharoplasty and Browplasty Revised Effective 6/1/21
Bronchial Thermoplasty Revised Effective 2/1/21
Centers for Medicare & Medicaid (CMS) and MassHealth Criteria and Guidelines Revised Effective 6/17/2021
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 8/1/2021
Clinical Trials - Medicare Revised Effective 8/1/2021
Clinical Review Criteria for Short Acting Opioids
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 Revised Effective 2/1/21
Deep Brain Stimulation Treatment New Effective 1/1/21
Drug Testing Revised Effective 2/1/21
Endothelial Keratoplasty Revised Effective 12/1/20
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 8/1/2021
Gait Trainers (MassHealth) Effective 4/1/18
Gardasil Protocol-HPV Vaccine
Gastric Electrical Stimulation Revised Effective 2/1/21
Gender Reassignment Surgery Revised Effective 8/1/2021
Genetic Testing Archived Effective 6/12/18
High Frequency Chest Wall Oscillation Devices Archived Effective 4/9/19
Home Health Aide- ADL Only Revised Effective 8/1/2021
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 4/1/2021
Implantable Miniature Ocular Telescope Prosthesis Archived Effective 5/14/19
Intacs Corneal Implants Revised Effective 12/1/20
Infertility Protocol Revised Effective 9/1/2021
Knee Arthroplasty and Knee Arthroscopy for MassHealth Archived Effective 1/1/2021
Knee Braces Revised Effective 9/1/2021
Laser-Assisted Uvulopalatoplasty or Uvulopalatopharyngoplasty Revised Effective 9/1/20
Lutetium LU 177 Dotatate, Therapeutic 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
Nodify Lung Nodule Risk Assessment - New Effective: 12/1/2020
Non-Covered, Experimental and Investigational Services Revised Effective 2/1/21
Orthognathic Surgery Revised Effective 8/1/2021
Outpatient Physical Therapy and Occupational Therapy Revised Effective 2/1/2021
Percutaneous Left Atrial Appendage Closure Revised Effective 12/1/20
Photochemotherapy, Phototherapy, Laser Treatments Revised Effective 6/1/21
Positive Airway Pressure Archived Effective 4/4/17
Preimplanataion Genetic Diagnosis (PDG) Revised Effective 6/1/21
Proton Beam Therapy Revised Effective 9/1/2021
Radiofrequency Ablation Revised Effective 6/1/21
Reconstructive Breast Surgery Revised Effective 9/1/2021
Reconstructive Repair of Pectus Excavatum or Pectus Carinatum Revised Effective 8/1/2021
Rhinoplasty Revised Effective 8/1/2021
Sacral Nerve and Electrical Percutaneious Tibial Nerve Stimulation Revised Effective 2/1/21
Sacroiliac Joint Fusion Revised Effective 9/1/2021
Skin and Soft Tissue Substitutes Revised Effective 2/1/21
Speech Generating Devices Archived 6/11/19
Speech Therapy Revised Effective 9/1/2021
Speech Therapy for Autism Disorders Revised Effective 4/1/2021
Spinal Cord Stimulation Revised Effective 6/1/21
Stretta Procedure Archived Effective 12/2/18
Surgical Management of Morbid Obesity Revised Effective 4/1/2021
Surgical Treatment of Gynecomastia Revised Effective 4/1/2021
Therapeutic Shoe and Orthotic Coverage Revised Effective 8/1/2021
Total Ankle Replacement Revised Effective 9/1/2021
Total Hip Resurfacing Archived 6/9/20
Transanal Endoscopic Microsurgery (TEMS) New Effective 4/1/2021
Transplants and Ventricular Assist Devices Revised Effective 9/1/2021
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 9/1/2021
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
To access the commonly used managed codes for Genetic Lab, Sleep Study Program or High Cost Imaging, log on to the
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
Provider Types Managed by Northwood vs. Health New England
Northwood Managed Codes
Northwood Commercial/Medicare Medical
Northwood Medicaid Medical Policies
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 email@example.com.
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 the Health New England Dedicated Line at (800) 985-9208 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.
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
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
Diagnosis and Management of Asthma
Immunization Schedule For Persons Aged 0 Through 6 Years
Pediatric Preventative Guidelines
Addendum To Neuropsychological Testing
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 nursey (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 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
autism professional services
bilateral and multiple professional and facility services
counseling and/or risk factor reduction intervention servicesnew effective 1/1/2021
discarded drugs and biologicals
emergency department services
evaluation and management
ground transportation services - archived
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
modifier new effective 9/1/20
newborn and neonatal care
non-covered, experimental & investigational services
non reimbursed revenue codes
neuropsychological and psychological testing
provider based billing
readmission to inpatient level of care
serious reportable events / provider preventable conditions
Skilled Home Health Care
Skilled Nursing Facility
telehealth (telemedicine) services
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.
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