NHP's FlexRx Pharmacy Program Resources
NHP's updated Drug Lookup webpage provides important pharmacy information to help you manage existing NHP plans as well as prepare for the upcoming FlexRx pharmacy program for 2016. These new pharmacy plans include 4-tier and 5-tier pharmacy options. In addition to the drug lookup tools, this webpage provides you access to the following pharmacy resources:
- Information on NHP's partnership with CVS/caremark
- Find a Pharmacy tool
- Benefit guides for 4-tier and 5-tier options
- Information on our over-the-counter (OTC) drug benefit
- A listing of low-cost drugs
- And much more!
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Notifying NHP of Practice Information Changes
Why is it important to let NHP know?
NHP displays the latest provider network information on our find-a-doc tool for our members to reference. When NHP is not notified timely of changes to your practice, members will see incorrect information. This may result in unnecessary calls to your office. For example, if a provider leaves your practice and NHP is not notified, members may continue to call to schedule an appointment.
How do I notify NHP of changes? To ensure that NHP members have the most up-to-date information about your practice, complete the Standardized Provider Information Change Form and email it to the Provider Credentialing Department at pec@nhp.org. This form should be used for the following:
- Practice name and address changes
- Billing information changes
- Panel status changes
- Provider termination requests
What resources are available?
NHPNet offers you various tools to help you manage your roster:
- Site Provider Roster Report - Providers currently affiliated with your site are listed on this report. The information on this report should be validated regularly, and NHP should be notified if there are any discrepancies. To access this report on NHPNet, click on Enrollment Reports link within the Reports tab.
- Primary Care Provider (PCP) Changes - When a provider leaves a primary care practice, members assigned to that individual provider must be reassigned to a new PCP before NHP can finalize the termination request. Through NHPNet, you can easily update a member's PCP to another PCP within your practice.
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Understanding Member Cost-Sharing
For members who are in a cost-sharing plan, it's important that they understand the potential costs they may incur throughout the year. In addition to paying a premium for health coverage, members may be subject to copayments, deductibles, or coinsurance. NHP makes this handy tool available to all commercial members as a way to better understand the basics of cost-sharing. Click Here to take a look inside.
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Coming Soon: Universal Neuropsychological Assessment Form
The Mass Collaborative recently developed a universal form for neuropsychological assessment prior authorization requests. This form will soon be made available in the Forms section of nhp.org/provider. Starting January 1, 2016, all requests for neuropsychological assessments with a medical diagnosis must be submitted on this form and faxed to NHP at 617-586-1700.
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Home Health Care Visits After a 60 Day Break In Service
As a reminder, a new home health care authorization is required when additional visits are requested and there is a 60 day break in service from the last authorized day. When additional visits are requested within 60 days from the last authorized day (including when members are admitted inpatient), the existing authorization should be revised. This requirement applies to all home health care disciplines including:
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Home Health Aide
- Medical Social Worker
- Private Duty Nursing
- Skilled Nursing
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NHPNet is an available resource to you that supports your management of NHP members. This tool provides you various capabilities such as verifying member eligibility, checking on a claims status, and verifying the status of authorizations/referrals. We constantly look for ways to enhance your experience with this tool to maximize the benefits to our network.
New Authorization/Referral Indicator
When reviewing the authorization/referral status for your NHP patient, a new Request Type indicator field will be available on the authorization/referral summary page for that patient. From the summary page, you will be available to differentiate authorizations from referrals prior to viewing detailed information for the individual authorization/referral.
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HEDIS Data Collection Starts In January
The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely-used standardized set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to help consumers compare health plan performance to other plans and to national or regional benchmarks. Each year NHP is required to collect and report HEDIS data from contracted providers. HEDIS data collection will begin in January 2016 and end in May 2016. A member of the NHP HEDIS staff will either schedule an onsite review at your location or ask that you fax or mail the information. Click Here to access the HEDIS FAQ
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Available Provider Resources on NHP.org/provider
NHP.org/provider is a central place to access important provider resources such as NHP's medical policies and information on NHP's quality improvement program. In addition, NHP.org/provider gives you direct access to NHP's provider manual, your resource for information on how effectively do business with NHP. Here's a look at some of the tools and information you can find on NHP.org/provider: - Medical Policies - NHP's medical policies provide you with the coverage criteria for the specified conditions. You can find more information on the utilization management (UM) decision making process and how to obtain UM criteria in the Provider Manual.
- Clinical Contact Information - Clinical staff is available Monday-Friday (8:30 AM - 5:00 PM). For after hours, you can contact: 1-855-444-4647
- Case Management and Disease Management Programs - For members who may benefit from case management or disease management programs, NHP.org provides you with information on specific programs and how you can refer a member
Provider Manual NHP's Provider Manual includes important information on how you can effectively do business with NHP. Topics include: - Quality Improvement Program - Information includes a description, processes, and goals.
- UM Decision Making - This includes information regarding NHP's decision making process and procedures. NHP does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, nor does NHP provide financial incentives to UM decision-makers to encourage decisions that result in under-utilization.
- Credentialing and Recredentialing Processes
- Member Rights and Responsibilities
- Practitioner Rights and Responsibilities
- Practitioner Appeal Processes
NHP's provider manual is accessible via nhp.org/provider. An updated version for 2016, will be available in soon. If you are unable to access the provider manual online, you may contact provider service at 1-855-444-4647 for alternative access.
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Applied Behavioral Analysis
Effective October 1, 2015, Neighborhood Health Plan began covering Applied Behavioral Analysis (ABA) services to members under age 21 with a medical need for ABA who are enrolled in MassHealth Standard or CommonHealth and to members under the age 19 enrolled in MassHealth Family Assistance. ABA is an evidence-based practice commonly used with individuals with a diagnosis of autism spectrum disorder. Based on the science of learning and behavior, ABA is considered a "best" practice treatment by the US Surgeon General and by the American Psychological Association. Treatment is provided in a variety of settings, such as the home and in the community. For further information related to authorization, medical necessity criteria, performance specifications, and billing for ABA services, please contact Beacon Health Options Provider Relations at Provider.Relations@beaconhs.com.
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The following medical policy has been revised (effective 12/1/15) and will be available on nhp.org:
- Enteral Nutrition Formulas and Supplements (All products) -
- Removed language under "Coverage for State-Mandated Conditions" indicating $5,000 annual limitation (item C).
- Removed Massachusetts regulation chapter 176G, section 4D.
Click Here to view all NHP medical policies.
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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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