Procedures, Treatments and Services Requiring Utilization Management (Nonbehavioral Health)
Customize your policy alerts
Sign up for all Health-New-England policy alerts
Know when Health-New-England releases new policies or updates existing guidance.
Monitor payer policy activity
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.
No material clinical or coverage changes in this revision.
Coverage Criteria and Notification Requirements
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
- Total Hip Resurfacing
- Upper Limb Prosthetic
- 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
Submission Codes and Timing
| Procedure Description and Code | Providers must include diagnosis, procedure description and code, units/days/visits when submitting requests. |
Provider Submission, Review, and Notification Actions
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.
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).
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.
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
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.