Important Provider Updates

Posted on April 22, 2016

Health New England has a number of important updates that may have an impact on your practice. Please review the following updates:

• Urine Drug Screen Payment Policy
• ClaimsXTen CMS Clinical Edit Update
• Pharmaceutical Waste Payment Policy
• Medicare First Tier, Downstream and Related Entities Training
• Updates on a number of Behavioral Health and Medical Clinical Policies

Urine Drug Screen Payment Policy
Health New England recognizes drug testing as an important part of a comprehensive approach to addiction treatment. Drug testing plays a role in diagnosis, evaluation, treatment and long-term monitoring of members with a substance use disorder. Our policy outlines a number of topics including but not limited to testing requirements, coverage guidelines for medical necessity and compensation/reimbursement information. The Urine Drug Screen Policy covers all Health New England lines of business.

For a full copy of the Urine Drug Screen Payment Policy, which has an effective date of 7/1/2016, please visit healthnewengland.org/providers/resources.

ClaimsXTen CMS Clinical Edit Update
Effective July 1, 2016, Health New England will be instituting a series of CMS Knowledge Pack Payment Rules. This implementation will refine Health New Englands current claims editing software. The software provides for an automated review of claims against accepted industry rules and coding guidelines. Sources for coding rules and edits may include but are not limited to the following: CPT, ICD, CMS, and Health New England Payment Policies. If a service is edited Health New England will provide an adjustment code with the Explanation of Payment.

To access Health New England’s Claims Editing Payment Policy as well as all other Health New England payment policies, please visit healthnewengland.org/providers/resources.

Pharmaceutical Waste Payment Policy Updates
Health New England has made clarifications in our current Pharmaceutical Waste Payment Policy. The updated payment policy includes, but is not limited to, requirements for single-dose as well as multi-dose administration and reimbursement guidelines. Included in the policy is a link to our drug formulary.

For a full copy of the revised Pharmaceutical Waste Payment Policy, which has an effective date of 7/1/2016, please visit healthnewengland.org/providers/resources.

Medicare First Tier, Downstream and Related Entities Training
The Centers for Medicare and Medicaid Services (CMS) issued a memo dated June 17, 2015, which was updated on February 10, 2016, by a memo entitled Additional Guidance – Compliance Program Training Requirements and Audit Process Update. The memos require First Tier, Downstream and Related Entities (FDRs) and providers (and certain of their employees) to complete general compliance as well as fraud, waste and abuse (FWA) training within 90 days of initial hire/contracting and annually thereafter.

FDRs deemed to have met the FWA training and education certification requirements through enrollment into Parts A or B of the Medicare program or through accreditation as a supplier of DMEPOS are NOT exempt from the general compliance training requirement.

Sponsors and/or FDRs have three (3) options for ensuring FDRs have satisfied the general compliance training requirement:

(1) FDRs can complete the general compliance and/or FWA training modules located on the CMS Medicare Learning Network (MLN). Once an individual completes the training, the system will generate a certificate of completion. The MLN certificate of completion must be accepted by Sponsors.

(2) Sponsors and FDRs can incorporate the content of the CMS standardized training modules from the CMS website into their organizations’ existing compliance training materials/systems.

(3) Sponsors and FDRs can incorporate the content of the CMS training modules into written documents for providers (e.g., Provider Guides, Participation Manuals, Business Associate Agreements, etc.).

Training courses are available on the CMS MLN online at learner.mlnlms.com. Health New England reserves the right to request an attestation or CMS certificate of completion confirming that the organization or provider has completed the appropriate general compliance and FWA training.

The Health New England provider manual will be updated accordingly to reflect this training requirement.

• Reducing the Burden of the Compliance Program Training Requirements
• Compliance Program Training Requirements and Audit Process Update

Clinical Criteria Updates
Health New England has recently reviewed our required clinical criteria related to the following:

• Female Reduction Mammoplasty and Breast Reduction
•  Speech Therapy
•  Positive Airway Pressure (PAP) Devices
•  Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain
•  INFUSE Bone Graft
•  Guidelines for Therapeutic Shoe and Orthotic Coverage
•  Depression Clinical Guideline
•  Preimplantation Genetic Testing (PGT)/Preimplantation Genetic Diagnosis

All updates made to the criteria have an effective date of 7/1/2016. For copies of the full clinical policies listed above, please visit healthnewengland.org/providers/resources.

Commercial Semi-Annual Notice of Changes
As part of our commitment to provide affordable access to high quality health care, Health New England continually reviews the benefits and services offered to our members. We then notify our fully funded members of changes to certain benefits and programs that are part of the standard benefit plan. Please note that our Semi-Annual Notice of Changes, effective 7/1/16, will be available online.

If you have questions regarding any of the included information, please contact Provider Relations at (800) 842-4464, ext. 5000.
A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.

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