Provider Manual

The Health New England (HNE) Provider Manual contains information, guidelines, and procedures that should be followed when rendering medical service to members and which are common to managed care in general. This edition of the HNE Provider Manual supersedes all previous editions. It includes information and changes for which providers have received written notification throughout the past year. Any additional material changes for which notification has not been provided will take effect 60 days from the distribution of this Manual. This edition of the Manual may also be found on the HNE secure website at HNEDirect.

Some of the guidelines and procedures in this Manual are based on requirements of State and Federal law as well as accrediting organizations. Thus the guidelines and procedures are subject to change if the requirements of the law or accrediting organizations change. HNE will notify providers in writing of modifications to this Manual that have a substantial impact on provider rights or responsibilities at least 60 days prior to the effective date of such modifications. Where there is a conflict between this edition of the Manual and a subsequent notification of a modification to a policy or procedure, the information in the subsequent notification shall prevail.

If providers have questions or recommendations about the information in this Provider Manual, they should contact Provider Relations at (800) 842-4464 ext. 5000. Representatives are available Monday-Friday from 8:00 am to 4:00 pm.

  • Member Eligibility and Identification Cards
  • Member Rights and Responsibilities
  • Confidentiality of and Access to Medical Records
  • Member’s Requesting Copies of Medical Records
  • Members’ Right to Appeal
  • Member Satisfaction Survey 
  • Provider Record Changes
  • Provider Address and Telephone Number Changes 
  • Physician Participation in PHOs or Medical Groups
  • Physician Primary Hospital Affiliation Changes/Additional Hospital Affiliations
  • Provider Tax Identification Number Changes
  • Provider Coverage Arrangements
  • PCP Panel Status Changes
  • PCP – Removing a Member from the Panel
PROVIDER COMMUNICATIONS 
REQUESTS FOR MEDICAL RECORDS
COORDINATION OF BENEFITS AND SUBROGATION
  • Coordination of Benefits Guidelines for Members with Other Health Insurance Coverage 
  • Coordination of Benefits Guidelines 
  • Coordination of Benefits Guidelines for Medicare Recipients When HNE is Secondary
  • Coordination of Benefits Guidelines in Automobile Accident Cases, or Where a Third Party is Liable 
  • Coordination of Benefits Guidelines for Workers’ Compensation Injuries
  • Subrogation
PRIOR APPROVAL PROCEDURES
  • Instructions for Requesting Prior Approval 
  • Procedures and Services Requiring Utilization Management (UM) Review:
  • Key Contact Telephone and Fax Numbers for Prior Approval Requests
  • Instructions for Completing the Standardized Prior Authorization Request Form
  • Instructions for Submitting the Standardized Prior Authorization Request Form
REIMBURSEMENT AND CLAIMS SUBMISSION
  • Scope of Services
  • Claims Procedure
  • Consult Codes
  • Assistant Surgeon Claims
  • Code 99000
  • Modifier 25
  • CPT Modifiers:
  • HNE’s Policy on HCPCS codes being billed by Physicians and Facilities.Error! Bookmark not defined.
  • Important Information Regarding All Claims 
  • Imaging Claims 
  • HNEDirect Provider On-line Services
  • HEDIS and the Provider Information Portal (PIP) through HNEDirect
  • Explanation of Payment (EOP) and Negative Balance Reports
  • HNE’s Vaccine Policy
PROVIDER APPEAL GUIDELINES AND REVIEW SHEET
DURABLE MEDICAL EQUIPMENT (DME)
HNE PRODUCTS AND BENEFITS
  • HMO Plans (Fully-Funded and Self Funded)
  • HNE Advantage Plus (Fully-Funded)
  • HNE Select Preferred (Self-Funded)
  • HNE Exclusive Provider Organization (EPO) Plan (Self-Funded)
  • Massachusetts Health Connector
  • CPI Physician Review-GIC/CPI product 
  • Emergency Services 
  • Infertility Service
  • Obstetrical and Gynecological Services
  • Annual Vision Exam
  • Chiropractic Benefit 
  • DME (Includes durable medical equipment, specialty medical equipment, medical and surgical supplies, orthotics and prosthetics, oxygen and respiratory supplies) 
  • Laboratory 
  • HNE Physician Office Allowable Lab Tests
  • Miscellaneous Services including Pain Management, Biofeedback, and Neuropsychological Testing
  • Provider Collection Policy
PHARMACY SERVICES
UTILIZATION MANAGEMENT, CASE MANAGEMENT & DISEASE MANAGEMENT
  • The purpose of HNE’s Utilization Management (UM)
  • Affirmative Statement Regarding Incentives
  • UM Review and Decision Process
  • Case Management
  • High Risk Member Case Management
  • Disease Management
  • Health Information Line (HIL)
  • Behavioral Health (BH)
  • Radiology Management Program
  • Clinical Transition Program
  • Appropriateness of Care Statement 
  • Affirmative Statement Regarding Incentives
  • Medical Technology Assessment Program
  • PCP Data
  • HIPAA Privacy Requirements and Patient Information Needed for Utilization Management, Case Management and Care Coordination
HNE CLINICAL GUIDELINES AND STANDARDS
  • Clinical Guidelines and Standards
  • Appointment and After-hours Standards
  • Medical Record Standards and Reviews 
  • Office Site Standards
  • Providing Care in a Culturally Competent Manner
PROFESSIONAL CREDENTIALING AND RECREDENTIALING
  • Providers Who Require Credentialing 
  • Providers Who Do Not Require Credentialing 
  • Healthcare Administrative Solutions, Inc. (HCAS)
  • Council for Affordable Quality Healthcare (CAQH)
  • Practitioner’s Rights
  • Facility Credentialing and Recredentialing
  • Quality Management Program (additional detail is available upon request)
  • Serious Reportable Events and Never Events
  • HEDIS
  • NCQA Accreditation
PROVIDER REVIEW AND CORRECTIVE ACTION
  • Introduction and Purpose
  • Provider Actions Warranting Further Review
  • Further Review and Corrective Action
  • Provider Appeals re: Disciplinary Matters
  • Important Note about Suspension and Termination
HNE CORPORATE COMPLIANCE PROGRAM (INCLUDING FRAUD, WASTE, AND ABUSE PREVENTION PROGRAM)
  • Compliance Statement and Code of Conduct
  • Reporting Concerns
  • Confidentiality and non-retaliation for good faith reporting:
  • Prompt response and corrective action: 
  • Enforcement of Standards through Well-Publicized Disciplinary Guidelines
  • Privacy and Security Program
  • Fraud, Waste, and Abuse Prevention Program
HNE