January 2014
Provider News 
Introducing The New NHP Provider e-Newsletter
We've simplified the look and feel of our Provider e-Newsletter. With this clean and simple format, you can easily read through the updates that are important to you and your organization. 

Click on the hyperlinks listed in the table of contents at the top to quickly go to the selected article.

We hope you enjoy the new format and we welcome your feedback (prweb@nhp.org).

Transition of Care 

Affordable Care Act 


To help you manage members who transition into a new NHP product (January 1-April 1), we have developed a transition of care plan to ensure a seamless experience.

For your reference, Click Here to view the Transition of Care FAQ.  

During this time of transition for our members, we offer a few helpful reminders that can prevent administrative challenges for health plans and providers:
  • Always refer to NHPNet to access the latest member eligibility information.  
  • If a patient indicates that they are an NHP member but you cannot verify eligibility on NHPNet, it is possible the MA Health Connector may have the latest eligibility status. Please note that from the time the member signs up, it may take a few business days for the Health Connector to process and send the eligibility file to carriers, and carriers a few business days to load the eligibility files into their systems. 
  • Once member eligibility is loaded into NHPNet, it may take up to 10 business days for the member to receive their ID card. These members can access an image of their temporary ID card by going to NHP.org/member and selecting "Print Temporary ID Card." Here is a sample of a temporary ID card: 


Commonwealth Care Extended to 3/31/14  

Affordable Care Act 


The State announced in November that Commonwealth Care members will have extended coverage until 3/31/14. NHP will continue to cover benefits and reimburse for services under the existing Commonwealth Care line of business for all eligible members until 3/31/14.

All Commonwealth Care members who qualify for Medicaid, will continue to be automatically re-enrolled by MassHealth on 1/1/14. For all other Commonwealth Care members, they will have until 3/24/14 to re-enroll for coverage that starts on 4/1/14. 
Click Here to view updates from the MA Health Connector

Section 1202 - PCP Rate Increase   

Affordable Care Act 


Over the past several weeks, Mass Health has signed off on overall approach for MCO implementation. NHP is implementing rate increases for eligible billed codes submitted by Primary Care Providers for calendar years 2013 and 2014. Please note the following:
  • Enhanced rates are for eligible codes* submitted by contracted primary care providers who function as a PCP with a qualifying specialty
  • Only codes that fall below Massachusetts ACA rates will be allowed the enhanced rate
  • Enhanced rates under Section 1202 will apply to codes billed during calendar years 2013 and 2014
  • Eligible providers will not be required to attest or complete an Amendment 

Over the new few months, NHP will reimburse PCPs for eligible codes billed in 2013 and 2014. Claims will be reimbursed in batches based on dates of service and reimbursements will be reflected on explanation of payments with ACA Section 1202 noted to the applicable line. Early in 2014, we will be configuring our system to automatically pay 2014 eligible codes at enhanced rates without reprocessing. 


*Eligible codes include:
  • Evaluation and Management codes 99201-99499 (or their successor codes)
  • Vaccine Administration codes 90460, 90461, 90471-90474 (or their successor codes) 

You Are Invited: MetroWest Regional Provider Meeting     

Affordable Care Act 


NHP Provider Relations is hosting a series of special regional meetings to engage our network on the Affordable Care Act.

Over the past few months, we held sessions on the Cape, Northeast, Southeast, and Greater Boston regions, as well as large and small forums at provider locations. With feedback from our providers that the information we are sharing is timely, valuable, and supportive to their practice operations and our members who may be experiencing coverage change, we will continue to engage our network in other areas.

With additional seats available at our upcoming MetroWest Regional Provider Meeting, sign-up today to reserve a spot (click on the RSVP link below).  

MetroWest Regional Provider Meeting:

Date:          January 24, 2014 
Time:         11:30-2pm 
Location:  Hampton Inn - Natick
                   319 Speen Street
                   Natick, MA 01760  
RSVP:       Click here to sign-up

Sleep Management Solutions Website

Effective February 3, 2014, NHP and Sleep Management Solutions (SMS) are pleased to announce that the website for processing prior authorizations will change. As you know, this program, administered by SMS since May of 2012, requires prior-authorization for all sleep services to include diagnostics, sleep therapy, and sleep therapy supplies.

The new website address is: www.sleepsms.com

Here is what you need to know:
  • If you are an existing website user on the older version (www.portal.sleepum.com), you will automatically be registered on the new website. Your username will be your email address, and your new password will be sent to you via email.
  • If you are an existing website user on the new version (www.sleepsms.com), you will not have to do anything - your user provider will be automatically updated to provide access to NHP. There are many users who already enrolled on the new website for purposes of doing prior authorizations with other SMS clients.
  • If you are not a registered user on either site, you can register by going to www.sleepsms.com and filling out the requested information (select 'Register' under the 'Username' sign in). Using the website for your prior authorization requests has some great features -
    • Now there is one site to process all your requests for all SMS clients
    • Electronic submission is available 24/7
    • Electronic submission avoids any discrepancies caused by having to hand-write your authorization requests
    • You can track your submissions without having to call for status information
    • You can select rendering providers more easily  
    • You can receive automatic approvals for all cases that do not need clinical review  
  • The new website will contain links to:
    • A website training module - this provides all the key things you need to know to enter authorization requests and to navigate the site
    • Information about Sleep Apnea
    • Information about Calling or Faxing your prior authorization request (a PDF version of the form is available for download)
    • SleepUM -the SMS patient management system
    • Updated news and items of interest
If you have any questions, please contact SMS Network Development at (888)497-5337 x181130
Access 90 and Mail Order Programs

For all new ACA-compliant plans effective January 1, 2014 and after, NHP will be eliminating the 30-day initial fill requirement prior to being able to request a 90-day supply of ongoing prescription refills at a reduced cost. With a prescription, members will be eligible for an initial 90-day supply of maintenance medications. Along with this change, these 90-day supply of medication will be available through Catamaran Home Delivery Mail Service.

New Standardized Provider Information Change Form      

To make sure that health plans and their members have the most up-to-date information about your practice, the Mass Collaborative* is pleased to introduce the Standardized Provider Information Change Form. When you are changing your practice name, address, phone numbers, e-mail, billing company, or other practice information, you only need to complete this single form and send it via e-email, fax, or US mail to each health plan you contract with instead of completing a different form for each health plan. 
This form should not be used to submit credentialing or contractual changes. Continue to use individual health plan forms for those changes. In some circumstances, individual health plans may need to follow up with providers for additional information regarding a demographic change.

For questions about specific health plan policies or requirement, contact that health plan directly.

*The Mass Health Collaborative is a multi-stakeholder group committed to reducing health care administrative burdens and costs. Members of the Mass Collaborative include the Massachusetts Hospital Association, Massachusetts Medical Society, Blue Cross Blue Shield of Massachusetts, the Massachusetts Association of Health Plans, the Massachusetts Health Data Consortium, MassHealth, Healthcare Administrative Solutions, as well as many local payers and providers.

Prior Authorization, Notification, and Referral Guidelines 



The Prior Authorization guidelines have been updated on 1/1/14 with the following changes:
  • Benefit limitations for MassHealth Essential and Basis removed
  • Acupuncture guidelines added  
  • Out of Network Providers of Service guidelines added

Click Here to view the Prior Authorization Grid  



Electronic Funds Transfer and Electronic Remittance Advice Registration Now Available 

Technology Update 


To sign up for EFT and ERA today, sign into NHPNet and click on any of the registration links from the homepage:


On the homepage, links to the registration form can be found under the

E-Business Tab and in the Explanation of Payment (EOP) Box

Starting February 1, 2014, providers currently receiving ERAs will no longer receive paper EOPs. Providers who register to receive ERAs will no longer receive paper EOPs within 31 days. All providers and designated staff members can view and print their EOPs at any time on NHPNet.


Clinical Coverage Criteria 



The following Clinical Criteria have been updated and are not available:
Click Here to view all Clinical Coverage Criteria

Lifting the Referral Requirement for Routine Vision 



As a reminder, effective October 1, 2013, NHP no longer requires a referral for in-network routine vision exams. This includes members who have an HVMA PCP.
Optometry Office Visits for Routine Eye ExaminationNo
Optometry Office Visits for Non-Routine Eye ExaminationYes
Ophthalmology Office Visits for Routine Eye ExaminationNo
Ophthalmology Office Visits for Non-Routine Eye ExaminationsYes

Eye Exams - Routine




Eye Exams - Non-Routine







Provider Manual 



The updated NHP Provider Manual is now available on NHP.org/provider.This manual is more than just your resource for NHP policies and procedures - it's your guide for doing business with NHP efficiently and effectively.

Click Here to view the Provider Manual

Group Insurance Commission Tiering  



NHP would like to share a couple of changes to the Group Insurance Commission (GIC) tiering process for FY 2015. 

First, effective July 1, 2014, NHP will no longer tier primary care provider sites. This decision is consistent with what other GIC health plans have done in previous years.      

Second, in early January 2014, if you practice one of the eight specialties tiered by NHP, you will receive a reporting packet containing your tier designation for each of the six health plans.  This consolidated packet will be sent on behalf of all six plans and, along with your tier designation, include summary and detail information on the quality and efficiency scores used to calculate your tier assignments.

As in previous years, the tier designations are derived by using claims data from all participating GIC health plans and aggregated by ViPS, Inc., and Resolution Health, Inc., the GIC's subcontractors.


Coronary Artery Disease

Healthwise Care Support


Did you know NHP's website offers Healthwise? Healthwise is an online health resource for our members providing in-depth articles and interactive tools to help them make wise health decisions, stay healthy, and live well. The article below focuses on some of the challenges impacting people with coronary artery disease.


What is coronary artery disease?
Coronary artery disease is the most common type of heart disease. It's also the number one killer of both men and women in the United States.
When you have it, your heart muscle doesn't get enough blood. This can lead to serious problems, including heart attack.

It can be a shock to find out that you have coronary artery disease. Many people only find out when they have a heart attack. Whether or not you have had a heart attack, there are many things you can do to slow coronary artery disease and reduce your risk of future problems.
What causes coronary artery disease?
Coronary artery disease is caused by hardening of the arteries, or atherosclerosis. This means that fatty deposits called plaque (say "plak") build up inside the arteries. Arteries are the blood vessels that carry oxygen-rich blood throughout your body.

Atherosclerosis can affect any arteries in the body. When it occurs in the ones that supply blood to the heart (the coronary arteries), it is called coronary artery disease.
When plaque builds up in the coronary arteries, the heart doesn't get the blood it needs to work well. Over time, this can weaken or damage the heart. If a plaque tears, the body tries to fix the tear by forming a blood clot around it. The clot can block blood flow to the heart and cause a heart attack.

What are the symptoms?

Symptoms can happen when the heart is working harder and needs more oxygen, such as during exercise. Symptoms include:
  • Angina (say "ANN-juh-nuh" or "ann-JY-nuh"), which most often is chest pain or discomfort or a strange feeling in the chest.
  • Shortness of breath.
  • Heart attack. A heart attack is sometimes the first sign of coronary artery disease.  

Less common symptoms include a fast heartbeat, feeling sick to your stomach, and increased sweating. Some people don't have any symptoms. In rare cases, a person can have a "silent" heart attack, without symptoms. 

How is coronary artery disease diagnosed?
Your doctor will do a physical exam and ask questions about your past health and your risk factors. Risk factors are things that increase the chance that you will have coronary artery disease.
Some common risk factors are being older than 65; smoking; having high cholesterol, high blood pressure, or diabetes; and having heart disease in your family.

If your doctor thinks that you have coronary artery disease, you may have tests to check how well your heart is working. These tests include an electrocardiogram (EKG or ECG), a chest X-ray, an exercise electrocardiogram, and blood tests. You may also have a coronary angiogram to check blood flow to the heart.
How is it treated?
Treatment focuses on lowering your risk for heart attack and stroke and managing your symptoms. Lifestyle changes, medicine, and procedures are used.
  • Lifestyle changes include quitting smoking (if you smoke), eating heart-healthy foods, getting regular exercise, staying at a healthy weight, lowing your stress level, and limiting how much alcohol you drink. A cardiac rehab program can help you make these changes.
  • Medicines can help you lower high cholesterol and high blood pressure, manage angina, and lower your risk of having a blood clot.
  • Procedures that improve blood flow to the heart include angioplasty and bypass surgery.

Thank You! 


On behalf of all of us at Neighborhood Health Plan, we thank you for the excellent care provided to our members and the continued collaboration extended to our staff.

Provider Relations Department
Neighborhood Health Plan