ProviderMatters

Local and National Coverage Determination Rules

Posted on March 30, 2021

Health New England continues to apply local and national coverage determination editing rules based on CMS policies. It is important when submitting claims to Health New England that you are familiar with the rules. For more information, go to https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx or https://www.ngsmedicare.com. In the “Continue as Guest” Box, select Part B Provider and your state. […]

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Telehealth and Waiving of Member Cost Share

Posted on March 30, 2021

Health New England continues to allow clinically appropriate and medically necessary telehealth services with our in-network providers through the state of emergency. We shared earlier that we will waive member cost sharing for COVID-19 and non-COVID-19 related medically necessary telehealth services.* The waiver of member cost sharing has been extended until June 30, 2021, for […]

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Pharmacy Refill on Prescription Contraceptives (Reminder)

Posted on March 30, 2021

Please be advised, Massachusetts law permits individuals with fully insured commercial health plan coverage to fill up to a 3-month supply on a first-time contraceptive prescription and up to a 12-month supply of prescription contraceptives after the first fill. For more information, go to healthnewengland.org/pharmacy or call your Provider Relations Representative at (800) 842-4464, extension […]

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MassHealth Dental Program

Posted on March 30, 2021

Health New England is helping to spread the word for Massachusetts Executive Office of Health and Human Services (EOHHS) on the MassHealth Dental Program. Effective January 1, 2021, patients over the age of 21, who have MassHealth coverage, are now able to access a greater number of dental services. EOHHS recommends when visiting with your […]

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Clinical Review Criteria Update – Radiofrequency Ablation

Posted on March 30, 2021

Policy Number: UM433POL Effective Date: 6/1/2021 LOB Affected: Commercial, Medicare, Medicaid Policy Type: Medical Added 11 definitions I., Criteria for Approval Added LCD link to use for all lines of business to determine if member meets criteria Original Sections I. and II. The information originally included in Sections I. and II. was deleted. II., What […]

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Clinical Review Criteria Update – Photochemotherapy (PUVA), Phototherapy, Laser Treatments

Posted on March 30, 2021

Policy Number: UM460POL Effective Date: 6/1/2021 LOB Affected: Commercial, Medicare, Medicaid Policy Type: Medical I., Criteria for Approval of Photochemotherapy (PUVA) with Psoralens (96912, 96913) C.:  Added 7. (Nursing mothers) and 8. (History of lupus erythematosus) III., A.: 4., b.: From:  b., Vitiligo when both criteria below are met: i., Involves <5 % of BSA; AND […]

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Clinical Review Criteria Update – Blepharoplasty and Browplasty

Posted on March 30, 2021

Policy Number: UM247POL Effective Date: 6/1/2021 LOB Affected: Commercial, Medicare, Medicaid Policy Type: Medical I., Criteria for Approval: Added “for Commercial and MassHealth” Added InterQual language for Commercial and Medicaid : Deleted statements 1-4 previously listed under section A. : Updated/corrected the link for Medicare for Blepharoplasty and Browplasty for Medicare Advantage (deleted Medicare LCD […]

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Clinical Review Criteria Update – Spinal Cord Stimulation

Posted on March 30, 2021

Policy Number: UM300POL Effective Date: 6/1/2021 LOB Affected: Commercial, Medicare, Medicaid Policy Type: Medical Definitions Added Nociceptive Pain and Spinal Cord Stimulator • I., Criteria for Approval B. o Added #2. o Changed 4: From: The treatment is a last resort, for chronic conditions with documentation of > 12 months of ineffective treatment and when […]

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