MassHealth Benefit Change: Acute Inpatient Hospital Coverage Limit Lifted for Members 21 Years of Age and Older
MassHealth 
Starting October 1, 2014, NHP MassHealth members 21 years of age and older will no longer be limited to up to 20 days per admission for acute hospital services. This change applies to all NHP MassHealth programs including MassHealth Standard, CarePlus, and Special Kids Special Care. For MassHealth members age 21 and older currently in an acute care hospital less than 20 days; the member now has an unlimited benefit. For members age 21 and older currently in an acute care hospital who have exhausted the 20 day benefit limit prior to 10/1/14; the member now has an unlimited benefit starting on 10/1/14. Requests for acute hospital services will continue to require authorization and will be reviewed based on medical necessity. Please remember to use NHPNet, the secure provider portal, to submit all requests for inpatient authorizations and extension requests. To review the User Guide for submitting inpatient authorizations, Click Here.
For additional information on authorization requirements, payment policies, and clinical coverage criteria, please visit nhp.org/provider.
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You Are Invited: NHPNet Training Webinars
NHPNet
NHP Provider Relations will be hosting a series of webinar trainings for NHPNet, the secure provider portal. These trainings are intended for providers who have recently activated/re-activated their NHPNet user account or for providers who would like an overview of NHPNet. In these trainings, we will review basic provider portal capabilities and offer best practice tips.
Register today to attend an upcoming session:
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Beginning December 1, 2014, All Claims for NHP HMO and MassHealth Members Should be Submitted Electronically, or to a New Mail Address
Claims
Coming soon, Neighborhood Health Plan (NHP) will be changing our address for original paper claims submissions. Starting with submissions on or after December 1, 2014, original paper claims for NHP HMO and MassHealth members should be sent to the following new address:
Neighborhood Health Plan PO Box 853908 Richardson, TX 75085-3908 Please continue to use the current mailing address for original paper claims until November 30th. After December 1st, the current mailbox will no longer be active. All claims mailed there will be returned. For PPO members, continue to use the claims address listed on the member ID card.
For appeals, adjustments, and other correspondence, continue to mail these to 253 Summer St, Boston, MA 02210.
Please be aware of new paper claims processing changes:
NHP recommends electronic claims submission as the preferred method of claims submission. Over 90% of claims are submitted electronically today. There will be no changes to the electronic claims process. NHP currently rejects claims when incomplete information is submitted such as member or provider information. Rejected claims are not processed and do not appear in NHP's system. Starting December 1st, we will make every effort to process all paper claims with incomplete information. We will only reject claims when certain critical fields are not complete. Once processed, the claim status will be viewable on NHPNet, the secure provider portal. These claims will also appear on your explanation of payments, which will be accessible on NHPNet within 30 days. To register for NHPNet, go to https://nhpnet.nhp.org and follow the registration instructions.
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Accessing Your Explanation of Payments on NHPNet
NHPNet 
On NHPNet, the secure provider portal, you can easily view your Explanation of Payments (EOPs). Follow the below steps to access your EOPs: - Log onto NHPNet. If you do not have an NHPNet account, sign up today at https://nhpnet.nhp.org. To view the NHPNet registration guide, Click Here.
- From the homepage, click on the Check Date field within the EOP section (see the image to the Right).
- A calendar window will appear. Select the appropriate EOP date and press Go.
Note: Your EOP will open as a PDF. You will need Adobe PDF Reader to view the document.
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Reclassification of Hydrocodone-Combination Drugs
Pharmacy
In an effort to combat prescription drug abuse, the U.S. Drug Enforcement Agency recently announced that hydrocodone-combination drugs (e.g. Vicodin, Lortab, Norco, and their generic equivalents) are being reclassified from Schedule III to Schedule II Controlled Substances effective October 6, 2014. Beginning October 6, 2014, prescriptions for hydrocodone-combination drugs will be subject to the following:
- Any remaining refills on an existing hydrocodone prescription will no longer be valid, and members will need to obtain a new prescription for these drugs.
- Prescribers can no longer write prescriptions that include refills for these drugs. Members will need a NEW prescription for EVERY fill.
- Prescriptions for these drugs will no longer be accepted via phone or fax.
- For members who use Catamaran Home Delivery, a written prescription for each fill must be mailed to Catamaran. Prescriptions for Schedule II drugs are not currently accepted via ePrescribing.
Please contact Catamaran if you have any questions.
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Durable Medical Equipment List Updates
Update
The following codes have been updated on the prior authorization list for durable medical equipment:
- S1034 (this code is non-covered and has been removed) - Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, blood glucose device, insulin pump and computer algorithm that communicates with all of the devices
- A9274 (Cost sharing comments revised) - External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
- E0784 (Cost sharing comments revised) - External ambulatory infusion pump, insulin
Click Here to view the Durable Medical Equipment Prior Authorization List .
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Authorization Submission Updates
Update
Chemotherapy Authorization UpdateComing soon, a Chemotherapy option will appear in the Requested Service drop-down menu when you create a new authorization request. Starting December 1, 2014, please use this option when requesting a Chemotherapy service for your patient.
Surgical Authorization ReminderSubmitting an authorization request with incomplete information may impact the review process. When submitting an authorization request for surgery, please remember the following requirements:
- Servicing Provider Field - Enter in the Facility
- Remarks Field - Enter the individual surgeon's name and group
Note: Authorizations that are not entered correctly as outlined in the User Guides will result in a claims denial. Click Here to view the User Guides for authorization submissions.
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Payment Policy Guidelines
Update
The following Payment Policy Guideline has been revised and is available on nhp.org:
Click Here to view all Payment Policy Guidelines.
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Clinical Coverage Criteria
Update
The following Clinical Coverage Criteria have been revised and are available on nhp.org:
Click Here to view all Clinical Coverage Criteria.
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Wait Time Access Standards
Reminder
NHP providers must ensure the availability of prompt provider consultation, including arrangements to assure coverage for members after hours. NHP also requires the hours of operation offered for all members to be the same regardless of their coverage.
In addition to after-hours access standards, patients should be seen within a reasonable time after their arrival. A reasonable time is defined as within 30 minutes of the appointment time.
Patient calls regarding active clinical problems and received during routing office hours should be returned within th hour when clinically appropriate or on a same day basis otherwise. Telephone calls regarding routine administrative requests should be returned within two business days.
Wait time access standards include the following:
- Emergency Services (including all necessary care coordination with home health, case management, behavioral health or other providers involved in the care of the member) must be provided immediately and be available 24 hours a day, seven days a week
- Primary Care
- Urgent - within 48 hours of the member's request
- Non-Urgent, Symptomatic - within 10 calendar days of the request
- Non-Symptomatic - within 45 calendar days of the request, unless an appointment is required sooner in order to ensure the provision of screenings in accordance with the MassHealth Early and Periodic Screening, Diagnosis and Treatment and Preventative Pediatric Healthcare Screening and Diagnosis Periodicity Schedule
- Specialty Care
- Urgent - within 48 hours of request
- Non-Urgent, Symptomatic - within 30 calendar days of the request
- Non-Symptomatic - within 60 calendar days of the request
- Behavioral Health
- Emergency and ESP Services (including all necessary care coordination with home health, case management, mental health or other providers involved in the care of the member) must be provided immediately and be available 24 hours a day, seven days a week
- For services described in an inpatient of 24-hour diversionary services discharge plan:
- Non-24-hour diversionary services - within two calendar days of discharge
- Medication Management - within 14 calendar days of discharge
- Other Outpatient Services - within seven calendar days of discharge
- Intensive Care Coordination Services - within the time frame directed by the Executive Office of Health and Human Services
- Urgent - within 48 hours of the request
- All Other Behavioral Health Care - within 14 calendar days
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Notification of Birth
Reminder
MassHealth's enrollment process for newborns (born to mothers enrolled in a Managed Care Organization) requires that the birth facility notify their enrollment unit via the Notification of Birth (NOB) form. This form captures demographic information for both mother and child and confirms the mother's health plan selection for the newborn.
We would like to remind network facilities that it's critical to submit the fully completed NOB to MassHealth in a timely fashion, thereby indicating the health plan chosen by the mother.
Failure to properly notify MassHealth often results in retroactive enrollment changes and the associated post-payment recoveries.
We ask that you please share this information with relevant personnel within your organization. For questions on completing the NOB, please contact Provider Relations at prweb@nhp.org.
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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.
Helen Connaughton
Director of Provider Relations
Neighborhood Health Plan
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