How HNE Makes Decisions on What and What Not to Cover
Posted on December 20, 2012
Have you ever wondered how we at Health New England (HNE) make our decisions on:
- what to cover,
- what not to cover, or
- what is or is not medically necessary?
We use a very detailed and regimented process:
- We use a set of criteria as a guide to make decisions.
- We use both commercially purchased and internally created criteria.
- We use evidence-based criteria, and our medical review board of community physicians approves the results.
HNE’s Utilzation Management team makes the decision based on the criteria. If a request for coverage does not meet our requirements for medical necessity, an HNE Medical Director reviews the request and all submitted information. If the clinical staff needs additional information to make the most informed decision, they contact your treating provider. HNE considers unique circumstances and needs in the context of the standards of care.
If we deny the request, we provide members with information regarding next steps for a provider peer review or an appeal. HNE strictly adheres to the requirements of two governing bodies: the Massachusetts Division of Insurance (DOI) and the National Committee for Quality Assurance (NCQA), for the following processes:
- how quickly the decision is made
- how the member is notified of the decision
- who makes the decision
- how the decision is made
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