Utilization Management
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Defines Health New England's utilization management program policies, processes, and decision-making for prior authorization, concurrent and retrospective review, and technology assessment affecting providers and members served by HNE.
No material clinical or coverage changes in this revision.
Coverage & Medical Necessity Criteria
Medical Necessity and Decision Process
Covered when determinations meet HNE medical necessity and appropriateness criteria:
HNE will notify providers and members 60 days prior to the effective date of any material changes to criteria.
Some self-funded plan sponsors may reserve final appeal decisions; HNE adheres to the plan sponsor/payer where applicable.
Providers may contact HNE Process Supervisor to request consideration of new technologies.
Reconsideration / Peer-to-Peer
Reconsideration allowed when adverse determinations occur:
If the adverse determination is not reversed, the insured or provider may pursue the formal grievance/appeal process; peer-to-peer reconsideration is not a prerequisite to filing a grievance or expedited appeal.
Call Health Services at (413) 233-4000, ext. 3470, or (800) 842-4464, ext. 3470.
Health New England generally does not perform retrospective (post‑service) review when a claim processed for the services is already on file. Retrospective review will be considered only in the defined circumstances: when a member is added retrospectively to HNE after services were provided or during ongoing treatment; when the member was referred or received same‑day services; when the service was urgent or emergent; or when enrollment/eligibility and/or member benefits cannot be verified. Denials following post‑service review may result from failure to follow administrative procedures, lack of medical necessity or appropriateness, or a benefit exclusion under the member's plan.
Provider Responsibilities & Prior Authorization
Prior Authorization / Pre-Service Review — Timing & Provider Responsibility
Pre-Service (Prior Authorization) and Concurrent reviews require providers to submit complete, accurate, and timely information. HNE will make an initial determination within two business days for pre-service reviews and within one business day for concurrent reviews after receiving all necessary information. Failure to provide required information prior to treatment or by the last day of an authorized stay may result in non-payment for administrative reasons.
- Providers must confirm member eligibility and benefits before services are rendered.
- For concurrent review, submit requests for extensions before the last authorized day of treatment or stay.
Delegated Prior Authorization Vendors
HNE delegates certain prior authorization and utilization management activities to external vendors. Providers may contact these delegated entities directly for status or submission questions. Delegated scopes include high-cost radiology/imaging, genetic testing, sleep studies, chiropractic services, pharmacy, medical injectables, and NICU management.
- eviCore: High-cost radiology, imaging, genetic testing, sleep studies — (888) 693-3211
- OptumHealth: Chiropractic services — (888) 676-7768
- OptumRx: Pharmacy issues — (800) 282-3232
- MagellanRx Management: Medical injectable drug program — (800) 424-8325
- ProgenyHealth: NICU management — (888) 832-2006
Use of Criteria for Therapy Pathways
HNE uses evidence-based, professionally developed criteria to implement therapy pathways, step-therapy and other utilization management rules. Criteria are reviewed and updated at least annually or more frequently when new accepted treatments or technologies emerge. Providers should follow required step or trial therapies when specified by the criteria to avoid denials.
- Criteria developed with input from practicing physicians and national standards bodies.
- Criteria sets are updated annually or sooner as clinical standards change.
- Commercially licensed criteria may specify step-therapy or prior trial requirements.
Required Submission Timing — Provider Obligations
Providers are responsible for submitting complete clinical documentation in a timely manner to support prior authorization or retrospective review requests. HNE expects submission of all necessary records by the timeframes above; failure to do so may result in administrative nonpayment or denial.
- Submit complete and accurate clinical information prior to treatment for pre-service reviews.
- For concurrent reviews, submit by the last day of authorized treatment or stay.
- Retrospective (post-service) review will be considered only when specific HNE criteria are met (for example, retrospective enrollment, same-day services, urgent/emergent care, or inability to verify eligibility).
Access to Criteria
Commercially purchased criteria sets used by HNE are licensed, proprietary, and confidential. HNE makes the portions of criteria used in decisions available to treating providers and members where required by law or accreditation standards. HNE-developed criteria for select services are publicly available on the HNE provider resources site.
- Licensed proprietary criteria are available to providers/members when legally required.
- HNE-developed criteria: http://healthnewengland.org/Providers/Resources
- HNE will notify members and providers 60 days prior to material changes in criteria.
Triggers for Denial — Administrative, Medical Necessity, and Benefit Exclusions
Denials can result from administrative failures (e.g., incomplete or untimely information), lack of medical necessity based on HNE criteria, or benefit exclusions under the member’s plan. Providers should ensure appropriate prior authorization, documentation of medical necessity, and verification of member benefits to reduce denial risk.
- Common denial triggers: incomplete or late submissions, failure to follow required step-therapy, services not meeting medical necessity criteria, and benefit exclusions.
- Retrospective review is not performed if a claim for services is already processed unless specific retrospective criteria are met.
Administrative Nonpayment Risk
Failure to provide timely and accurate information may lead to administrative nonpayment or denial of claims. Providers bear the risk of nonpayment when they do not obtain required prior authorization, fail to submit information within required timeframes, or submit incomplete documentation that prevents HNE from making a determination.
- Administrative nonpayment risk applies when necessary information is not submitted before treatment or by the end of an authorized stay.
- Providers should obtain and document prior authorization approvals to avoid financial liability.
Definitions — Review Types
Background & Program Scope
Utilization management evaluates the medical necessity and appropriateness of services to facilitate timely, appropriate care and accurate claims payment. HNE conducts three types of review: pre‑service (prior authorization), concurrent (inpatient/ongoing stay and extensions), and post‑service (retrospective) reviews. The Medical Technology Assessment Committee systematically evaluates new technologies to inform coverage decisions and ensure that determinations align with clinical evidence and program standards.
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