CurrentHealth-New-EnglandPolicy N/A

Procedures, Treatments and Services Requiring Utilization Management (Nonbehavioral Health)

Defines services, procedures and treatments (non-behavioral health) that require prior authorization, notification, concurrent or retrospective review by Health New England and its delegates; applies to providers and facilities billing HNE plans.

Policy Summary

PayerHealth-New-England

PolicyProcedures, Treatments and Services Requiring Utilization Management (Nonbehavioral Health)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit the Standardized Prior Authorization Request Form with supporting clinical documentation; form should be received at least seven days prior to scheduled service when possible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledelegate vendors

requiredstandard form required

7lead time (days)

requiredemergency notification

Coverage Criteria and Notification Requirements

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inv-01: Prior Authorization and Delegated Services

Services requiring prior authorization by HNE include, but are not limited to, the following categories and procedures. Some services are delegated to external vendors as noted.

ALL of the following

ANY of the following
- All requests for Out-Of-Plan providers for HMO plans
- All elective admissions to an Out-Of-Plan facility for PPO/POS plans
All admissions to a skilled nursing facility or inpatient rehabilitation facility
Transplants
ALL of the following
- Abdominal Panniculectomy
- Blepharoplasty
- Reduction Mammoplasty
- Orthognathic Surgery
- Autologous Chondrocyte Transplant
ALL of the following
- Rhinoplasty
- Sacral Nerve Stimulation
- Spinal Cord Stimulation
- Scleral Lens
- Speech Generating Devices
- Speech Therapy (outpatient except when part of Home Health Care benefit)
- Surgical Management of Morbid Obesity
Durable Medical Equipment and related services: Durable Medical Equipment for Home Infusion and Sleep Studies (note: other DME is managed by Northwood)
Home infusion, home care and specialty Rx providers billing for supplies/equipment related to infusion/parenteral/tube-fed nutrition (prior authorization via Health New England)
Sleep study professional services (managed by eviCore)
Formula and enteral nutrition
Gastric Electrical Stimulation
Laser-Assisted Uvulopalatoplasty
Lyme Disease Treatment
Mandibular Advancement Device for Obstructive Sleep Apnea
Outpatient Hyperbaric Oxygen Therapy
Positive Airway Pressure Devices
Clinical Trials
Cardiac Monitoring

inv-02: Notification Requirements

Services requiring notification only:

ALL of the following

Emergency admissions — notify Health Services via fax to (413) 233-2700 or call Health Services at (413) 787-4000, extension 5027 or (800) 842-4464, extension 5027
Pregnancy — following the first prenatal visit submit the ACOG Antepartum Record or Obstetrical Pre-Registration form to Health Services; resubmit if a new risk factor is identified

inv-03: Concurrent and Retrospective Review

Review timing categories:

ALL of the following

Concurrent review — applies to inpatient admissions, after-hour and weekend inpatient admissions, ongoing services beyond the initial authorization period (e.g., skilled home care, infusion therapy, outpatient speech therapy) and discharge planning
Retrospective review — applies to emergency services

inv-04: Infertility Coverage Note

Special state-mandated coverage note for infertility:

ALL of the following

All infertility treatments (AI, IUI, IVF, GIFT, ZIFT, FET) require prior authorization; prior authorization forms are available on the HNE website or by contacting Health Services
Infertility services are mandated benefits in Massachusetts for Massachusetts residents and in Connecticut for Fully Funded plans; Self-Funded plans may opt out
For detailed clinical and coverage rules, refer to the Infertility Protocol Policy on the HNE Providers Resources page

Provider Submission, Review, and Notification Actions

Prior Authorization

Prior Authorization Submission Requirements

Submit the Standardized Prior Authorization Request Form to Health Services with complete supporting clinical documentation (statement of medical necessity, office notes, lab results, imaging/x‑ray reports, and consultation reports). The form should be received at HNE at least seven days prior to the scheduled service when possible. Fax to (413) 233-2700 or mail to Health New England, One Monarch Place, Suite 1500, Springfield, MA 01144. The requesting provider is responsible for submission; missing information may delay review.

Include diagnosis, procedure description and code, and units/days/visits requested when applicable.
Attach copies of pertinent clinical information (statement of medical necessity, office notes, lab results, x‑ray/imaging reports, consultation reports).
If required information is missing, HNE may request additional information, delaying decision.

Prior Authorization

Services Requiring Prior Authorization / Delegated Review

Obtain prior authorization from Health New England for services it manages and contact the specified delegate vendors for services they manage (e.g., eviCore, OptumHealth, Northwood, MagellanRx, AMR). Verify the appropriate manager and direct requests to that entity.

Services managed by HNE include out‑of‑plan provider requests for HMO, elective out‑of‑plan facility admissions for PPO/POS, all admissions to skilled nursing or inpatient rehab, transplants, designated surgical procedures, formula and enteral nutrition, infertility treatments, and others listed.
High‑cost imaging, genetic testing and sleep studies: contact eviCore (888‑693‑3211).
Chiropractic care: contact OptumHealth (888‑676‑7768).
Durable medical equipment: contact Northwood (877‑807‑3701).
Medical injectable drugs: contact MagellanRx Management (800‑424‑8325).
Non‑emergency scheduled transport services: contact AMR (866‑585‑6438).

Documentation Required

Concurrent Review Requirements

Follow concurrent review requirements for inpatient and ongoing services: inpatient admissions (including after‑hours and weekend admissions), ongoing services beyond the initial authorization period (e.g., skilled home care, infusion therapy, outpatient speech therapy), and discharge planning are subject to concurrent review.

Notify Health Services per HNE procedures for concurrent review during the admission or as services continue beyond authorized periods.
Concurrent review applies to discharge planning and after‑hours/weekend inpatient admissions.

Denial Risk

Retrospective Review for Emergency Services

Emergency services are subject to retrospective review by Health New England; providers must notify HNE as required and be prepared to submit documentation after the event.

Emergency admissions require notification to Health Services (fax to (413) 233-2700 or call Health Services at (413) 787-4000 as noted).
Retrospective review means documentation for emergency services will be reviewed after care is provided.

Form and Vendor Definitions

Standardized Prior Authorization Request Form — inv-11

Form nameStandardized Prior Authorization Request Form — the form providers must submit with supporting clinical documentation to request prior authorization from Health New England.

Required attachmentsAttach pertinent clinical information such as a statement of medical necessity, office notes, lab results, imaging reports and consultation notes.

Submission methodsFax the completed form to Health Services at (413) 233-2700 or mail to Health New England, One Monarch Place, Suite 1500, Springfield, MA 01144.

Outcome communicationHealth Services will send written confirmation of the decision to the requesting physician, rendering provider, the member and the member's PCP; denials for medical necessity are also communicated by phone to the referring provider.

Delegated prior authorization/notification vendors — inv-12

eviCore healthcareManages high-cost imaging studies, genetic lab testing and sleep studies; contact: (888) 693-3211.

OptumHealthManages chiropractic care (notification required); contact: (888) 676-7768.

NorthwoodManages durable medical equipment; contact: (877) 807-3701.

MagellanRx ManagementManages medical injectable drugs; contact: (800) 424-8325.

American Medical Response (AMR)Manages non-emergency (scheduled) transport services; contact: (866) 585-6438.

OpenPayer

Procedures, Treatments and Services Requiring Utilization Management (Nonbehavioral Health)

Coverage Criteria and Notification Requirements

Submission Codes and Timing

Provider Submission, Review, and Notification Actions

Form and Vendor Definitions