Authorization Submissions
Submitting an authorization request with incomplete information may impact the review process. When submitting an authorization request for surgery, please remember to always specify the following information:
- Facility Information - Enter in the "Servicing Provider" field
- Surgeon's Information - Specify the individual provider and group in the "Remarks" field
If the facility or provider information is not appropriately entered on the authorization request, or if there is any mismatch between the authorization and your submitted claim, your claim will deny.
For more information on how to submit authorization requests, Click Here to view the Authorization User Guides.
Appealing a Claims Denial
For denied claims, you have the option to initiate the claims appeal process by completing the "Request for Claims Review Form" and including any relevant supporting documentation. Please enter all required fields on this form prior to submitting it to NHP. Incomplete forms will be returned and not processed. Completed forms will be sent for review, and you will be notified of the determination to uphold or overturn the original decision.
For more information on the appeals process, Click Here to view NHP's Provider Manual.
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Provider Termination Requests
Reminder
When a provider leaves your practice, please remember to always notify NHP of this change. This ensures that your latest provider roster information accurately displays in NHP's Provider Directory. With accurate roster information, we can help reduce the number of incorrect member calls to your office looking for a provider who is no longer in your practice. Also, we can avoid sending you correspondence addressed to a provider who is no longer in your practice.
For Primary Care Providers (PCP) who leave your practice, please remember to re-assign their members to another PCP within your site via NHPNet. Termination requests cannot be completed until all members are re-assigned.
Notifying NHP is simple. Complete the Provider Termination Form and email it to pec@nhp.org.
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CAQH ProView™ to Launch in February
Credentialing
In February, CAQH will launch a new version of the Universal Provider DataSource - CAQH ProView™. In this version you will notice a new look and feel to the website, as well as enhancements such as the ability to join CAQH directly and upload supporting documents. For all pending data that you have entered into the system, you will need to attest to the information for it to be converted into CAQH ProView™.
For more information, Click Here to to read the CAQH ProView™ frequently asked questions.
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MassHealth Renewals
MassHealth
As a reminder, MassHealth is required to review and re-determine member benefits on an annual basis. Due to system issues, this process was suspended starting in the Fall of 2013. With improved system functionality, MassHealth has reinstated regular renewals using Modified Gross Adjusted Income (MAGI) methodologies for all non-disabled and non-senior members. Members who qualify for automatic renewals will be notified that no further action is required. For those who must reapply, MassHealth will send out a notification with instructions on when and how to submit their renewal application. For the fastest way to reapply for coverage, it is recommended that members submit their application online at MAhealthconnector.org. Members who do not reapply by the specified deadline will lose coverage. Checking Member Eligibility
As a member's eligibility status can change from one day to another, it is best practice to regularly verify eligibility. Please remember to always check member eligibility in NHPNet, the secure provider portal, prior to rendering services. NHPNet provides you with the latest eligibility information. For additional assistance through the renewal process, MassHealth members can contact the MassHealth Customer Service Center at 1-800-841-2900 (TTY: 1-800-497-4648).
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The following Medical Policies have been updated and are available on nhp.org:
Click Here to view all NHP Medical Policies.
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Checking Member Eligibility
Reminder
Members who obtain their health coverage through the MA Health Connector are required to pay monthly premiums. If a member fails to pay their premium timely, they have up to 3 months to settle their account. During this period, Health Plans are required to notify you when a member is in a payment delinquency status and there's a possibility that claims for services rendered during this time will deny. NHP will notify you if a member is in a delinquency status through the following ways: - Prior to rendering a service, always verify eligibility on NHPNet. Members who are in a delinquent status will show as: "Active - PI*" on the member eligibility search screen:
 If you view a member's detail page, the eligibility status will indicate " Active - Pending Investigation" and the member's delinquency effective date will be displayed:  - For Medical and Behavioral Health services rendered while a member is in a delinquent status, the claim will pend and indicate "Awaiting Eligibility Determination":
- All Pharmacy claims submitted when a member is in a delinquent status will deny.
If the member settles their account prior to the end of the 3rd month, their eligibility status becomes "Active" and all pended claims will process. If the member fails to settle their account prior to the end of the 3rd month, their eligibility status becomes "Inactive" and all pended claims will deny.
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Form 1099-MISC To Be Mailed Out By Week of February 23
Reminder
In accordance with IRS regulations, please be advised that form 1099-MISC (Miscellaneous Income) will be mailed by the week of February 23, 2015. Please allow 10 business days for delivery. Additional copies will be available beginning on March 9, 2015. Please contact NHP Provider Services at 855-444-4647 or providerservice@nhp.org with any questions.
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Quarterly Hospital Admissions Report
Update
The latest quarterly hospital admissions report is now available. To view this report, click on the Reports tab in NHPNet and select Clinical Reports. If you do not have access to NHPNet, you may register online at https://nhpnet.nhp.org or contact Provider Relations at prweb@nhp.org for assistance.
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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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