Please read this letter carefully for updates on our audit program policy, appointment and after-hours standards and our provider\/pharmacy directory requirements.<\/p>\n
Audit Program Policy<\/strong> The areas reviewed under Health New England\u2019s Provider Audit Program include but are not limited to the following:<\/p>\n \u2022 Vendor audits for Provider Patient Accounts and Credit Balance The policy outlines each area included in our audit program, general guidelines as well as the Provider Rebuttal\/Appeal Process.<\/p>\n For a full copy of the revised Audit Program Policy please visit: Appointment and After-hours Standards<\/strong> To access a copy of our standards in the Health New England Provider Manual, please visit www.healthnewengland.org\/provider-manual<\/a>.<\/p>\n Provider\/Pharmacy Directory Requirements<\/strong> You can communicate any updated information to Health New England in one of three ways:<\/p>\n \u2022 Visit our forms library online at www.healthnewengland.org\/forms<\/a>. You will need to click on the \u201cProviders\u201d 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<\/a> 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.<\/p>\n","protected":false},"excerpt":{"rendered":" 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[4],"tags":[],"class_list":["post-2236","post","type-post","status-publish","format-standard","hentry","category-informational-purposes-only"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZHB-A4","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/2236","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/comments?post=2236"}],"version-history":[{"count":3,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/2236\/revisions"}],"predecessor-version":[{"id":2240,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/2236\/revisions\/2240"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=2236"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=2236"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=2236"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
\nEffective 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.<\/p>\n
\n\u2022 DRG validation audits
\n\u2022 Line-item provider bill audits
\n\u2022 Duplicate billing\/services
\n\u2022 Intentional misrepresentation
\n\u2022 Billing services at a higher level than which was rendered
\n\u2022 Professional code reviews (CPT and Modifier Review)
\n\u2022 Claim audits to validate compliance with the contract, plan policies and procedures, relevant guidelines, laws and regulations
\n\u2022 Performance of unwarranted or medically unnecessary services for the purpose of financial gain<\/p>\n
\nwww.healthnewengland.org\/providers\/resources<\/a><\/p>\n
\nHealth 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\u2019s 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.<\/p>\n
\nAccurate 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.<\/p>\n
\n\u2022 Email our Provider Enrollment team directly at penrollment@hne.com
\n\u2022 Log into HNEDirect (www.hnedirect.com\/login<\/a>). Once you are logged in, click the last tab on the main page entitled Change Provider Info.<\/p>\n