ProviderMatters

Clinical Review Criteria (August 2024)

Posted on August 5, 2024

Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org/Providers/Resources. Once on the Resources page, click on Behavioral Health/Medical Policies to learn more. Percutaneous Neuroablation Effective 8/1/2024 Updated with non-coverage of Intraosseous Basivertebral Nerve Ablation (CPT codes 64628 and 64629) as it is not covered by MassHealth. Cosmetic and Reconstructive Procedures […]

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Formulary Update (July 2024)

Posted on July 2, 2024

Health New England’s formularies are located at healthnewengland.org. At the top of the page, use the “Find A Drug” tool. Prescription Drug Coverage- Commercial Note: Tier 1 – lowest copay level; Tier 2 – mid copay level; Tier 3 – highest copay level For 5-tier formulary- Tier 4-lowest specialty tier; Tier 5-highest specialty tier Step […]

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Payment Policy (July 2024)

Posted on July 2, 2024

Health New England is committed to reviewing our internal procedures, and defining coverage and billing guidelines with applicable laws and industry standards to ensure our policies are appropriate. To access payment policies, please visit healthnewengland.org/Providers/Resources. Discarded Drugs & Biologicals Effective 6/1/2024 Reviewed with no changes Evaluation & Management Professional Services Effective 6/1/2024 Removal of expired codes […]

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Clinical Review Criteria (July 2024)

Posted on July 2, 2024

Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org/Providers/Resources. Once on the Resources page, click on Behavioral Health/Medical Policies to learn more. Breast Surgery Updated to remove reference to Schnur Sliding Scale as this scale is no longer used No change to effective date of 8/1/2024   Prostate Procedures (BPH […]

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Payment Policy (June 2024)

Posted on June 4, 2024

Health New England is committed to reviewing our internal procedures, and defining coverage and billing guidelines with applicable laws and industry standards to ensure our policies are appropriate. To access payment policies, please visit healthnewengland.org/Providers/Resources. Vaccines & Immunizations Effective 5/1/2024 Added Industry Standard Language Added additional language to Non-State Supplied Vaccines under Commercial Conditional Formatting Inpatient […]

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Formulary Update (June 2024)

Posted on June 4, 2024

Health New England’s formularies are located at healthnewengland.org. At the top of the page, use the “Find A Drug” tool.   Brand Name Generic Name GPI Commercial Formulary status Aphexda MRX MOTIXAFORTIDE ACETATE 82502050102150 PA thru Magellan, T4 Daxxify MRX DAXIBOTULINUMTOXINA-LANM 90890045402140 PA thru Magellan, T4 Elrexfio MRX ELRANATAMAB-BCMM 213520281520** PA thru Magellan, T4 Eylea […]

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Clinical Review Criteria (June 2024)

Posted on June 4, 2024

Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org/Providers/Resources. Once on the Resources page, click on Behavioral Health/Medical Policies to learn more. Nutritional counseling No changes.   Lymphedema- Surgical Treatment No changes.   Blepharoplasty and Browplasty No changes.   Cosmetic and Reconstructive Procedures Criteria in section E4 clarified; no other […]

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Health Equity

Posted on June 1, 2024

The mission of Health New England is to improve the health and lives of the people in our communities, and we are deeply committed to those individuals we serve every day. In addition, we believe everyone must have the opportunity to attain their full health potential with no disadvantage due to social or socially assigned […]

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Electronic Visit Verification (EVV) Overview Forum Invitation

Posted on May 16, 2024

ATTENTION:  HOME HEALTH, SKILLED NURSING, OT/PT SPEECH THERAPISTS, PCA The Massachusetts Executive Office of Health and Human Services (EOHHS) is hosting an upcoming Electronic Visit Verification (EVV) Overview Forum to inform providers, health plans, and other key stakeholders of the EVV solution and implementation. Please distribute to your Home Health, Personal Care Services, and Aging Services […]

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Clinical Review Criteria: May 2024

Posted on April 26, 2024

Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org/Providers/Resources. Once on the Resources page, click on Behavioral Health/Medical Policies to learn more. Skin and Soft Tissue Substitutes: Updated MassHealth coverage due to new Guidelines for Medical Necessity Determination for Skin Substitutes. Q4159 Affinity, and Q4196, PuraPly now covered for this […]

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