60 Day Notice Audit Policy
Posted on February 12, 2016
Please read this letter carefully for updates on our audit program policy, appointment and after-hours standards and our provider/pharmacy directory requirements.
Audit Program Policy
Effective May 1, 2016 Health New England will issue a replacement version of our Audit Program Policy. The objective of this policy is to ensure Health New England fulfills our responsibility to our risk-sharing partners, members and Plan sponsors by identifying and recovering inaccurate payments which are the result of inadvertent or intentional provider actions or misrepresentations, including incorrect coding and billing.
The areas reviewed under Health New England’s Provider Audit Program include but are not limited to the following:
• Vendor audits for Provider Patient Accounts and Credit Balance
• DRG validation audits
• Line-item provider bill audits
• Duplicate billing/services
• Intentional misrepresentation
• Billing services at a higher level than which was rendered
• Professional code reviews (CPT and Modifier Review)
• Claim audits to validate compliance with the contract, plan policies and procedures, relevant guidelines, laws and regulations
• Performance of unwarranted or medically unnecessary services for the purpose of financial gain
The policy outlines each area included in our audit program, general guidelines as well as the Provider Rebuttal/Appeal Process.
For a full copy of the revised Audit Program Policy please visit:
www.healthnewengland.org/providers/resources
Appointment and After-hours Standards
Health New England has long established Appointment and After Hours Standards that have been made readily available in the Health New England Provider Manual. As part of HNE’s ongoing effort to ensure members have appropriate and timely access to care, we are sending out this refresher to remind you to review these standards.
To access a copy of our standards in the Health New England Provider Manual, please visit www.healthnewengland.org/provider-manual.
Provider/Pharmacy Directory Requirements
Accurate provider/pharmacy directories are critical to helping our members make educated decisions about their plan choices. Health New England offers an online directory for all of our products. In addition, hard copies of each directory are available upon request. In an effort to support both CMS and NCQA requirements, we will be outreaching to our In-Network Providers on a quarterly basis to validate their information. We will ask for validation on the following, but not limited to; address, phone number, office hours, availability to new patients, etc.
You can communicate any updated information to Health New England in one of three ways:
• Visit our forms library online at www.healthnewengland.org/forms. You will need to click on the “Providers” tab and choose the Provider Information Change Form. This form can also be accessed by using the following URL: https://www.hcasma.org/attach/Provider_Information_Change_Form.PDF
• Email our Provider Enrollment team directly at penrollment@hne.com
• Log into HNEDirect (www.hnedirect.com/login). Once you are logged in, click the last tab on the main page entitled Change Provider Info.
If you have any questions regarding any of the included information, please contact Provider Relations at 1-800-842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 4:30 p.m.
