POLICIES & RESOURCES

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.

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 and Excision of Excessive Skin and Subcutaneous Tissue: Revised Effective 10/1/25
• Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue: Revised Effective 12/1/26
• Achalasia and Gastroesophageal Reflux Disease (GERD) - Minimally Invasive Procedures: Revised Effective 10/1/25
• Ambulatory Electrocardiograph Monitoring: Revised Effective 8/1/26
• Artificial Cervical Intervertebral Disc: Revised Effective 10/1/25
• Autologous Chondrocyte Implantation or Transplantation: Effective 6/1/26
• Azedra (iobenguane I-131): Revised Effective 10/1/25
• Bariatric Surgery: Revised Effective 4/1/26
• BH Admission and Concurrent Review Criteria for ASAM 3.5: Revised Effective 10/1/25
• BH Admission and Concurrent Review Criteria for ASAM 3.5: Effective 10/1/26
• BH Applied Behavioral Analysis for Down Syndrome: Revised Effective 1/27/26
• BH Community-Based Acute Treatment/Youth Clinical Crisis Stabilization (CBAT/YCCS) Program and Intensive Community-Based Acute Treatment (ICBAT) Program: Revised Effective 10/1/25
• BH Community-Based Acute Treatment/Youth Clinical Crisis Stabilization (CBAT/YCCS) Program and Intensive Community-Based Acute Treatment (ICBAT) Program: Effective 10/1/26
• BH Community Crisis Stabilization (CCS): Revised Effective 11/1/25
• BH Community Crisis Stabilization (CCS): Effective 10/1/26
• BH Day Treatment: Revised Effective 10/1/25
• BH Day Treatment: Effective 10/1/26
• BH Drug Testing in Substance Use Disorder Treatment and Pain Management: Revised Effective 1/1/26
• BH Family Stabilization Team: Effective 11/1/25
• BH Family Stabilization Team: Effective 10/1/26
• BH Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP): Effective 8/14/25
• BH Intensive Outpatient Program (IOP) Partial Hospitalization Program (PHP): Effective 10/1/26
• BH Inpatient Rehabilitation (ASAM Level 3.7) for Substance Abuse: Revised Effective 10/1/25
• BH Inpatient Rehabilitation (ASAM Level 3.7) for Substance Abuse: Effective 10/1/26
• BH Neuropsychological Testing, Psychological Testing, and Neurobehavioral Status Exam: Revised Effective 10/1/25
• BH Neuropsychological Testing, Psychological Testing, and Neurobehavioral Status Exam: Effective 10/1/26
• BH Recovery Coaching (RC): Effective 11/1/25
• BH Recovery Coaching (RC): Effective 10/1/26
• BH Recovery Support Navigator (RSN): Effective 11/1/25
• BH Recovery Support Navigator (RSN): Effective 10/1/26
• BH Transcranial Magnetic Stimulation: Revised Effective 11/1/25
• BH Transcranial Magnetic Stimulation (TMS): Revised Effective 8/1/26
• BH Transcranial Magnetic Stimulation (TMS): Effective 10/1/26
• Blepharoplasty and Browplasty: Effective 4/1/26
• Bone Grafts and Stabilization Devices for Spinal Defects: Revised Effective 10/1/25
• Bone Grafts and Stabilization Devices for Spinal Defects: Revised Effective 12/1/26
• Bone Mineral Density Measurement: Effective 6/1/26
• Breast Surgery: Revised Effective 6/1/26
• Bronchial Thermoplasty: Effective 11/1/24
• Cardiac Contractility Modulation for Heart Failure: New Effective 6/1/26
• Chimeric Antigen Receptor T-Cell Therapy: Revised Effective 6/1/26
• Clinical Trials: Revised Effective 10/1/25
• Clinical Trials: Effective 10/1/26
• Cochlear Implants BAHA (Bone-Anchored Hearing Aid) ABI (Auditory Brainstem Implant) Bone-Conduction Hearing Aid: Revised Effective 2/1/26
• Contact Lens (Therapeutic): Effective 2/1/26
• Corneal Remodeling for Refractive Errors: Effective 1/1/26
• Cosmetic and Reconstructive Procedures: Revised Effective 10/1/25
• Cosmetic and Reconstructive Procedures: Revised Effective 12/1/26
• Dental Anesthesia and Procedures: Effective 1/1/26
• Gender Affirming Services: Effective 7/15/25
• Genetic Testing: New Effective 2/1/26
• GIC Fertility Services (GIC insured members only): Revised Effective 7/1/26
• Home Health Care Services (Commercial and Medicare): Effective 10/1/25
• Home Health Care Services (MassHealth): Effective 11/1/25
• Hospice and Palliative Care: New Effective 11/1/25
• Hospice and Palliative Care: Revised Effective 12/1/26
• Hyperbaric Oxygen (HBO) Therapy: Revised Effective 10/1/25
• Hyperbaric Oxygen Therapy: Revised Effective 12/1/26
• Infertility Treatment: Revised Effective 4/1/26
• Infertility Treatment: Revised Effective 12/1/26
• Infertility Treatment (Baystate Health ASO): Effective 8/1/25
• Intracameral Implants: New Effective 9/1/26
• Intradialytic Parenteral Nutrition: Revised Effective 7/1/26
• Insertion of Implantable Wireless Pulmonary Artery Pressure Sensor and Monitoring (i.e., CardioMEMS): Revised Effective 6/1/25
• Leadless Cardiac Pacemaker: Revised Effective 12/1/26
• Lipodystrophy Syndrome – HIV Associated: Effective 10/1/25
• Lipodystrophy Syndrome – HIV Associated: Revised Effective 12/1/26
• Long-Term Acute Care (LTAC): New Effective 10/1/25
• Long-Term Acute Care (LTAC): Revised Effective 12/1/26
• Leadless Cardiac Pacemaker: New Effective 10/1/25
• Lutetium Therapeutic Radiopharmaceuticals: Effective 2/1/26
• Lymphedema - Surgical Treatment: Revised Effective 6/1/26
• Lutetium Therapeutic Radiopharmaceuticals: Effective 2/1/25
• Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor: New Effective 6/1/26
• Medical Necessity and Experimental and Investigational: Revised Effective 9/1/26
• Musculoskeletal Surgery: Arthroplasty: Revised Effective 4/1/26
• Neurostimulators: Revised Effective 8/1/26
• Non-Emergent Transportation: Effective 10/1/25
• Non-Emergent Transportation: Effective 10/1/26
• Nutritional Counseling for Eating Disorders: Effective 6/1/26
• Outpatient Physical and Occupational Therapy: Revised Effective 6/1/26
• PANS/PANDAS: Effective 2/1/26
• Percutaneous Left Atrial Appendage Closure: Revised Effective 2/1/26
• Percutaneous Neuroablation: Revised Effective 8/1/26
• Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS): Revised Effective 1/1/26
• Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS), Percutaneous Electrical Nerve Field Stimulation (PENFS): Revised Effective 8/1/26
• Photochemotherapy: Revised Effective 6/1/26
• Preimplantation Genetic Testing: Revised Effective 2/1/26
• Preimplantation Genetic Testing: Effective 10/1/26
• Prostate Procedures (BPH and Prostate Cancer): Revised Effective 6/1/26
• Prostate Procedures: Revised Effective 12/1/26
• Proton Beam Therapy: Effective 10/1/25
• Proton Beam Therapy: Revised Effective 7/1/26
• Reconstructive Repair of Pectus Deformity: Effective 9/1/25
• Reconstructive Repair of Pectus Deformity: Revised Effective 7/1/26
• Renal Denervation for Uncontrolled Hypertension: Revised Effective 6/1/26
• Rhinoplasty and Other Nasal Surgeries: Effective 6/1/26
• Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain: Revised Effective 9/1/25
• Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain: Revised Effective 12/1/26
• Skin and Soft Tissue Substitutes: Revised Effective 6/1/26
• Sleep Disordered Breathing Diagnosis and Treatment: Revised Effective: 2/1/26
• Sleep Disordered Breathing Diagnosis and Treatment: Revised Effective 12/1/26
• Speech Language Pathology (SLP) Services: Revised Effective 2/1/26
• Speech Therapy for Autism Disorders: Revised Effective 2/1/26
• Spinal Cord And Dorsal Root Ganglion Stimulation: Effective 1/1/24
• Superficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers: New Effective 8/1/26
• Transcatheter Aortic Valve Replacement (TAVR): Effective 6/1/26
• Transcatheter Mitral Valve Repair: Revised Effective 2/1/26
• Transcatheter Pulmonary Valve Implantation (TPVI): Effective 6/1/26
• Transcatheter Tricuspid Valve Interventions: Revised Effective 9/1/26
• Transplants: Effective 1/1/26
• Tumor Treatment Fields: Revised Effective 2/1/26
• Varicose Veins and Venous Insufficiency: Effective 1/1/26
• Ventricular Assist Devices: Revised Effective 4/1/26
• Virtual Cardiac Rehabilitation: New Effective 2/1/26

Abdominal Panniculectomy: Revised Effective 4/1/23

Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue: Effective 3/1/24

Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue: Effective 9/1/24

Achalasia and Gastroesophageal Reflux Disease (GERD) - Minimally Invasive Procedures: Effective 2/1/24

Achalasia and Gastroesophageal Reflux Disease (GERD) - Minimally Invasive Procedures: Revised Effective 1/1/25

Ambulatory Cardiac Monitoring: Effective 6/1/23

Ambulatory Cardiac Monitoring: Revised Effective 1/1/24

Ambulatory Electrocardiograph Monitoring: Revised Effective 7/1/25

Ambulatory Electrocardiograph Monitoring: Effective 4/1/24

Ambulatory Electrocardiograph Monitoring: Effective 7/16/24

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

Artificial Cervical Intervertebral Disc: Effective 2/1/24

Artificial Intervertebral Cervical Disc: Effective 11/1/24

Autologous Chondrocyte Implantation Or Transplantation: Revised Effective 9/1/23

Autologous Chondrocyte Implantation or Transplantation: Revised Effective 4/1/24

Autologous Chondrocyte Implantation or Transplantation: Revised Effective 6/1/25

Azedra: Effective 11/1/24

Azedra (iobenguane I-131): Effective 2/1/24

Azedra: Revised Effective 12/1/22

Balloon Dilation Of The Eustachian Tube: Revised Effective 6/1/23

Balloon Dilation Of The Eustachian Tube: Effective 8/1/24 (Retired 3/1/25)

Bariatric Surgery: Revised Effective 8/1/23

Bariatric Surgery Revised Effective 6/1/24

Bariatric Surgery: Revised Effective 6/1/25

BH ABA For Autism Spectrum Disorders: Revised Effective 1/5/23

BH Applied Behavioral Analysis for Autism Spectrum Disorder: Effective 2/1/24

BH Applied Behavioral Analysis for Autism Spectrum Disorder: Effective 2/1/25

BH Applied Behavioral Analysis for Autism Spectrum Disorder: Revised Effective 9/1/25

BH Applied Behavioral Analysis for Autism Spectrum Disorder: Revised Effective 1/27/2026

BH Applied Behavioral Analysis for Down Syndrome: Revised Effective 1/1/26

BH Admission For Concurrent Review ASAM 3.5: Revised Effective 2/1/24

BH Admission for Concurrent Review ASAM 3.5: Effective 4/1/24

BH CBAT: Revised Effective 6/1/23

BH CBAT.ICBAT Effective 4/1/24

BH Community Crisis Stabilization (CCS): Effective 2/1/24

BH Community Crisis Stabilization (CCS): Effective 4/1/24

BH CSU: Revised Effective 11/3/22

BH Day Treatment: Revised Effective 5/5/22

BH Day Treatment: Effective 2/1/2024

BH Day Treatment: Effective 6/1/24

BH Family Stabilization Team: Effective 2/1/24

BH FST: Revised Effective 11/3/22

BH Inpatient Admissions And Concurrent Review For Substance Abuse Disorder: Revised Effective 10/1/23

BH Inpatient Rehabilitation (ASAM Level 3.7) for Substance Abuse: Effective 6/1/24

BH Masters Level And Licensed Outpatient Therapists: Revised Effective 1/5/23

BH Neuropsychological Testing: Effective 2/1/2024

BH Neuropsychological Testing: Revised Effective 5/5/22

BH Neuropsychological Testing, Psychological Testing and Neurobehavioral Status Exam: Effective 6/1/24

BH Transcranial Magnetic Stimulation: Revised Effective 11/3/22

BH Transcranial Magnetic Stimulation: Effective 2/1/24

BH Transcranial Magnetic Stimulation: Effective 6/1/24

Blepharoplasty And Browplasty: Revised Effective 5/1/23

Blepharoplasty and Browplasty: Revised Effective 6/1/24

Blepharoplasty and Browplasty: Revised Effective 7/1/25

Bone Grafts For Spinal Defects: Revised Effective 11/1/23

Bone Grafts and Stabilization Devices for Spinal Defects: Effective 9/1/24

Bone Mineral Density Measurement: Effective 8/1/25

Breast Surgery: Effective 8/1/24

Breast Surgery: Revised Effective 11/1/24

Breast Surgery: Revised Effective 8/1/25

Breast Surgery: Revised Effective 10/1/25

Bronchial Thermoplasty: Revised Effective 2/1/24

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

Chimeric Antigen Receptor Therapy: Effective 10/1/24

Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Revised Effective 1/1/25

Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Revised Effective 4/1/25

Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Effective 7/1/25

Clinical Trials: Revised Effective 7/1/23

Clinical Trials: Effective 9/1/24

Cochlear Implant, BAHA, ABI, Bone Conduction HA: Effective 7/1/23

Cochlear Implant: Revised Effective 12/1/24

Cochlear Implants, BAHA (Bone-Anchored Hearing Aid) ABI (Auditory Brainstem Implant), ABI (Auditory Brainstem Implant), Bone-Conduction Hearing Aid: Revised Effective 10/1/25

Contact Lenses: Effective 12/1/22

Contact Lens (Therapeutic): Effective 2/1/24

Contact Lens (Therapeutic): Effective 2/1/25

Corneal Cross Linking: Revised Effective 2/1/23

Corneal Remodeling for Refractive Errors: Effective 3/1/24

Corneal Remodeling for Refractive Errors: Revised Effective 1/1/25

Cosmetic And Reconstructive Procedures: New Effective 11/1/23

Cosmetic and Reconstructive Procedures: Revised Effective 6/1/24

Cosmetic and Reconstructive Procedures: Effective 9/1/24

Deep Brain Stimulation Treatment

Deep Brain And Cortical Stimulation: Revised Effective 1/1/24

Deep Brain and Cortical Stimulation: Revised Effective 1/1/25

Archived Effective 6/1/25; see Neurostimulators

Dental Anesthesia And Procedures: Revised Effective 1/1/24

Dental Anesthesia and Procedures: Revised Effective 1/1/25

Dental Anesthesia: Effective 6/1/23

Drug Testing: Revised Effective 10/1/23

Drug Testing in Substance Use Disorder Treatment and Pain Management: Effective 3/1/24

Drug Testing in Substance Use Disorder Treatment and Pain Management: Revised Effective 3/1/25

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: Effective 2/1/24

Gastric Electrical Stimulation: Revised Effective 1/1/25

Archived Effective 6/1/25; see Neurostimulators

Gender Affirming Services: Effective 2/1/25

Gender Affirming Services: Revised Effective 11/1/23

Gender Affirming Services: Effective 4/1/24

GIC Fertility Services (GIC insured members only): Effective 7/1/25

High Intensity Focused Ultrasound (HIFU) For Prostate Cancer: Effective 9/1/22

See Prostate Procedures

Home Health Care Services: Revised Effective 8/1/23

Home Health Care Services (Commercial and Medicare): Effective 10/1/24

Hydrogen Breath Testing: Retired Effective 1/1/24

Hyperbaric Oxygen (HBO) Therapy: Revised Effective 4/1/23

Hyperbaric Oxygen (HBO) Therapy: Revised Effective 3/1/25

Implantable Neurostimulators: New Effective 4/1/25

Infertility Protocol: Revised Effective 12/1/22

Infertility Treatment: Effective 2/1/24

Infertility Treatment: Effective 5/1/24

Infertility Treatment (Baystate Health ASO): Effective 1/1/25

Intacs Corneal Implants: Revised Effective 12/1/22

See Corneal Remodeling for Refractive Errors

Insertion Of Wireless Pulmonary Artery Pressure Sensor & Monitoring (I.E., Cardiomems): Revised Effective 11/1/23

Insertion Of Wireless Pulmonary Artery Pressure Sensor & Monitoring  (I.E., Cardiomems): Effective 9/1/24

Intradialytic Parenteral Nutrition: New Effective 11/1/24

Intradialytic Parenteral Nutrition: Revised Effective 9/1/25

Infertility Treatment: Effective 2/1/25

Infertility Treatment: Revised Effective 7/1/25

Knee Braces: Retired Effective 11/1/23

Knee Braces - Please Refer To DME Section For Northwood Criteria

Laser-Assisted Uvulopalatoplasty Or Uvulopalatopharyngoplasty: Effective 9/1/22

See Sleep Disordered Breathing

Lipodystrophy Syndrome – HIV-Associated: Effective 3/1/24

Lipodystrophy Syndrome – HIV associated: Revised Effective 1/1/25

Lutetium Therapeutic Radiopharmaceuticals: Effective 2/1/24

Lymphedema - Surgical Treatment: New Effective 10/1/23

Lymphedema - Surgical Treatment Revised Effective 6/1/24

Lymphedema - Surgical Treatment: Revised Effective 6/1/25

Medical Necessity

Medical Necessity And Experimental And Investigational: Revised Effective 1/1/24

Medical Necessity And Experimental And Investigational: Effective 1/15/25

Medical Necessity and Experimental and Investigational: Revised Effective 10/1/25

Musculoskeletal Surgery: Arthroplasty: Effective 1/1/25

Neurostimulators (previously Implantable Neurostimulators): Revised Effective 6/1/25

Nodify Lung Nodule Risk Assessment: Retired Effective 12/1/23

Non-Covered, Experimental And Investigational Services: Retired Effective 1/1/24

See Medical Necessity And Experimental And Investigational

Non-Emergent Transportation: New Effective 11/2/24

Nutritional Counseling For Eating Disorders: New Effective 4/1/23

Nutritional Counseling for Eating Disorders: Revised Effective 6/1/24

Nutritional Counseling for Eating Disorders: Revised Effective 7/1/25

Orthognathic Surgery: Revised Effective 6/1/23

Orthognathic Surgery: Effective 11/1/24

Outpatient Physical Therapy And Occupational Therapy: Revised Effective 2/1/23

See Physical and Occupational Therapy

Outpatient Physical and Occupational Therapy: Revised Effective 3/1/25

PANS/PANDAS: Revised Effective 2/1/24

PANS/PANDAS: Effective 2/1/25

Percutaneous Left Atrial Appendage Closure: Revised Effective 12/1/22

Percutaneous Left Atrial Appendage Closure: Effective 2/1/24

Percutaneous Neuroablation (formerly Radiofrequency Ablation): Effective 8/1/24

Percutaneous Neuroablation: Revised Effective 7/1/25

Percutaneous Left Atrial Appendage Closure: Revised Effective 3/1/25

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)

Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS): Effective 3/1/25

Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS): Revised Effective 7/1/25

Peroral Endoscopic Myotomy (POEM): New Effective 12/1/22

See Achalasia and Gastroesophageal Reflux Disease (GERD)

Photochemotherapy (PUVA) - Phototherapy, Laser Treatments: Revised Effective 1/1/24

Photochemotherapy (PUVA) - Phototherapy, Laster Treatments, Photodynamic Testing (PDT): Effective 7/1/24

Photochemotherapy (PUVA) - Phototherapy - Laser Treatments - Photodynamic Therapy (PDT): Revised Effective 7/1/25

Physical and Occupational Therapy: Effective 2/1/24

Preimplantation Genetic Testing: Revised Effective 5/1/23

Preimplantation Genetic Testing: Effective 7/1/24

Preimplantation Genetic Testing: Revised Effective 7/1/25

Prostate Procedures (BPH and Prostate Cancer): Effective 3/1/24

Prostate Procedures (BPH and Prostate Cancer): Effective 9/1/24

Prostate Procedures (BPH and Prostate Cancer): Revised Effective 1/1/25

Prostate Procedures: Revised Effective 9/1/25

Proton Beam Therapy: Revised Effective 10/1/23

Proton Beam Therapy: Effective 9/1/24

Radiofrequency Ablation: Effective 9/1/22

Radiofrequency Ablation For Spinal Pain: Updated Effective 12/1/23

Was Previously Radiofrequency Ablation

Reconstructive Breast Surgery: Retired Effective 11/1/23

Reconstructive Repair Of Pectus Excavatum Or Pectus Carinatum: Revised Effective 6/1/23

Reconstructive Repair of Pectus Deformity Reconstructive Repair of Pectus Deformity: Effective 9/1/24

Recovery Coaching (RC): Effective 1/1/25

Recovery Support Navigator (RNS): Effective 1/1/25

Renal Denervation for Uncontrolled Hypertension: New Effective 2/1/26

Rhinoplasty: Revised Effective 6/1/23

Rhinoplasty and Other Nasal Surgeries: Effective 9/1/24

Rhinoplasty and Other Nasal Surgeries: Revised Effective 10/1/25

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation: Revised Effective 2/1/23

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation: Effective 3/1/24

Archived Effective 4/1/25; see Neurostimulators

Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain: Effective 7/1/24

Sacroiliac Joint Fusion: Revised Effective 7/1/23

Skin and Soft Tissue Substitutes: Revised Effective 4/1/26

Skin and Soft Tissue Substitutes: Revised Effective 2/1/24

Skin and Soft Tissue Substitutes: Effective 6/1/24

Skin and Soft Tissue Substitutes: Revised Effective 3/1/25

Skin and Soft Tissue Substitutes: Revised Effective 6/1/25

Skin and Soft Tissue Substitutes: Revised Effective 7/1/25

Sleep Disordered Breathing Diagnosis: New Effective 10/1/23

Sleep Disordered Breathing Diagnosis and Treatment: Effective 3/1/24

Sleep Disordered Breathing Diagnosis and Treatment: Revised Effective 3/1/25

Speech Language Pathology (SLP) Services

Speech Therapy: Revised Effective 8/1/2022

See Speech Languages Pathology (SLP) Services

Speech Language Pathology (SLP) Services: Effective 2/1/24

Speech Language Pathology (SLP) Services: Revised Effective 12/1/24

Speech Therapy For Autism Disorders: Revised Effective 6/1/23

Speech Therapy for Autism Disorders: Revised Effective 12/1/24

Spinal Cord Stimulation

See Spinal Cord And Dorsal Root Ganglion Stimulation

Surgical Treatment Of Gynecomastia: Retired Effective 11/1/23

See Breast Surgery

Total Ankle Replacement: Effective 9/1/22

Transanal Endoscopic Microsurgery: Effective 4/1/23

Transanal Endoscopic Microsurgery: Retired Effective 1/1/25

Transcatheter Aortic Valve Replacement (TAVR) New Effective 9/1/24

Transcatheter Aortic Valve Replacement (TAVR): Effective 10/1/25

Transcatheter Mitral Valve Replacement New Effective 10/1/24

Transplants And Ventricular Assist Devices

Transplants And Ventricular Assist Devices: Revised Effective 9/1/22

Transplants: Effective 2/1/24

Transplants: Effective 2/1/25

Transcatheter Tricuspid Valve Interventions: New Effective 10/1/25

Transcatheter Pulmonary Valve Implantation (TPVI): New Policy Effective 6/1/25

Transcatheter Tricuspid Valve Interventions: Revised Effective 2/1/26

Transurethral Water Jet Ablation: Revised Effective 2/1/23

See Prostate Procedures

Treatment Of Lipodystrophy Syndrome (LDS): Revised Effective 12/1/22

Tumor Treatment Fields (TTFS) (I.E., Optune Device): Revised Effective 12/1/22

Tumor Treatment Fields: Effective 2/1/24

Tumor Treatment Fields: Effective 2/1/25

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

Varicose Veins and Venous Insufficiency: Revised Effective 1/1/25

Varicose Veins and Venous Insufficiency: Revised Effective 7/1/25

Ventricular Assist Devices: Effective 2/1/24

Ventricular Assist Devices: Revised Effective 3/1/25

Water Vapor Thermal Therapy (Rezum): Effective 9/1/22

See Prostate Procedures

Health New England has selected Northwood Inc. as its Durable Medical Equipment Benefit Manager (DBM) for certain provider types.

As the DBM, Northwood will oversee all aspects of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS). This includes:

• Prior authorization
• Provider contracting and management
• Provider appeals
• Member services
• Claims payment

Northwood vs. Health New England Benefit Management

• Prior Authorization Procedure List
• Provider Types Managed by Northwood vs. Health New England
• For those exceptions where Health New England will manage the DMEPOS benefit, please go to https://healthnewengland.org/forms and click “Clinical Request Forms.”

Participating Northwood Providers Northwood providers must utilize Northwood’s online provider portal to submit authorization requests for prescribed DMEPOS supplies.

• https://providerportal.northwoodinc.com

Non-Participating Northwood Providers Authorization requests from non-participating providers may be faxed to Northwood.

• 1-877-552-6551
• Prior Authorization Form
• 1-877-807-3701

Urgent or Emergent Requests Providers may also contact Northwood to request an authorization by phone for urgent/emergent requests (i.e. hospital discharge).

Northwood Medical Policies:

• https://northwoodinc.com/northwood-commercial-medicare-nh-medicaid-medical-policies/ 
• https://northwoodinc.com/northwood-medicaid-medical-policies/

For more information on submitting authorization requests, claims, and appeals see the Provider Quick Reference Guide.

• 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.

Click here for more information on CLAS 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.

2025 HNE Community Health Needs Assessment (updated every three years)

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.

Other available resources

For more information on interpreter services available to you, follow the links below.

https://www.mass.gov/interpreter-services-at-health-care-facilities (Specific to MassHealth)

Limited English Proficiency (LEP) | HHS.gov

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.

Multilingual Interpreter Rights and Requests for Help posters and cards | Mass Legal Services

https://portal.ct.gov/-/media/DPH/Office-of-Health-Equity/I-SPEAK/I-SPEAK-cards/2018/ASL-index.pdf

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

Click here to access the Interqual® Transparency Self-Registration website.

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.

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 65 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 65 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 65 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 65 days from the date they received the explanation of payment notice, not 65 days from receiving the notice indicating a WLS is still needed to process the appeal.
• if the WLS is received within the 65 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.

Health New England has partnered with EviCore by Evernorth for prior authorization services of select CT, MR, Nuclear Cardiac, PET, and Genomic Lab studies.

Prior Authorization Procedure Lists:

• Radiology & Cardiology
• Laboratory Management

Contact Information

Client Services: 888-693-3211 (Available Monday - Friday 8am - 9pm ET)

Website: https://www.evicore.com/

Provider Portal

EviCore highly recommends providers take full advantage of the online capabilities in their Provider Portal. Here you can request prior authorization, review evidence-based guidelines, and receive announcements about program updates. Access requires only your email address and a brief registration. To register click here.

Frequently Asked Questions | EviCore by Evernorth

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.

The Site of Service program, directs members to the most cost- effective, clinically appropriate location to receive their infusion(s) of select specialty medications as listed in this policy.

Learn more

Click here to view services that require prior authorization.

View our annual reports on Prior Authorization Metrics for Medical Items and Services:

• Medicare Advantage HMO
• Medicare Advantage PPO
• BeHealthy Partnership Plan

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