Authorizations and Referrals
Authorization and Referral System Enhancements to Go-Live on September 1NHP is dedicated to ensuring an optimal provider experience when requesting authorizations and referrals. To support this effort, NHP is launching several enhancements to our authorization and referral intake system on September 1, 2016. These enhancements will result in a more streamlined submission process and improve authorization/claim matching functionality. Provider webinar trainings have been scheduled to review the new features and how to effectively submit your request. To register, click on the link that corresponding to the session you would like to attend:
- For Primary Care Providers
- For Outpatient Rehab and Homecare Providers
- For All Providers and Facilities
Reminder: Select the Correct Servicing Provider Location
When requesting authorizations or referrals, you will need to conduct a search for the appropriate
servicing provider. Your search result may pull up multiple site locations and affiliations. Remember to always select the provider based on the appropriate site location where the service will be rendered and the appropriate provider group/facility. Claims may be impacted if the pay-to provider doesn't match the requested provider on the authorization or referral. 
Adverse Determinations
Prior to finalizing adverse determinations, NHP medical directors have often provided courtesy calls to the requesting physicians in addition to providing the final decision via mail and NHPNet notifications. Starting on August 1, 2016, NHP medical directors will no longer routinely provide courtesy calls. Please continue to utilize NHPNet for the latest status information.
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Reminder: New UM Programs Go-Live August 1
Effective August 1, 2016, the following utilization management programs require prior authorization through eviCore Healthcare: Non OB-Ultrasounds, Selected Cardiac Imaging & Diagnostic Services, Selected Molecular & Genetic Testing, Radiation Therapy.
Click Here for more information such as a listing of CPT codes that require authorization and the clinical guidelines.
How to Request Authorization
Note: To access eviCore's online portal and submit authorization requests, you must register for an account.
Phone: 1-888-693-3211
This reference guide is available for more information on how to submit authorization online. For questions regarding the authorization process or registration for the online portal, please contact eviCore at clientservices@evicore.com.
Register for a Provider Orientation Webinar
Provider orientation webinars are available on the following dates:
- Tuesday, August 2 @ 9 AM EST (Non-OB Ultrasound and Cardiac Imaging)
- Tuesday, August 2 @ 3 PM EST (Molecular Genomic Testing)
- Wednesday, August 3 @ 9 AM EST (Molecular Genomic Testing)
- Thursday, August 4 @ 1 PM EST (Non-OB Ultrasound and Cardiac Imaging)
- Thursday, August 4 @ 3 PM EST (Radiation Therapy)
Click Here to register. Click on the "Training Center" tab to find the session you would like to attend.
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High-Tech Radiology Quick Reference Guides
Quick Reference Guides are available for your reference when submitting high-tech radiology prior authorization requests. These quick reference guides outline what information is required for the requested study so that all pertinent information can be included in the initial request and that unnecessary delay or denials can be avoided. Click Here to view the quick reference guides for high-tech radiology. 
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Annual Provider Satisfaction Survey
In August, NHP will send out the annual Provider/Office Manager satisfaction survey. Completed surveys will be entered to win a Kindle Fire. Your feedback will be useful to determine what ways NHP can better serve our network. We thank you in advance, and appreciate your time and feedback.
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Appointment Access and Commercial Membership Surveys
Thank you for completing the Appointment Access and NHP's Commercial Membership Growth surveys in July. All completed entries were entered to win a Kindle Fire. Congratulations to the following winners:
- Jennifer Bonnilla - Family Health Center of Worcester
- Susan Fili - Yuil Medical Associates
Reminder: Appointment Access Standards
To ensure that patients have easy access to high quality health care services and can easily get the care they need in a timely manner, the appointment access standards include:
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Request
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Primary Care Provider
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Specialty Care
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Urgent care
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Within 48 hours
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Within 48 hours
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Routine symptomatic care
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Within 10 days
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Within 30 days
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Routine non-symptomatic care
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Within 45 days
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Within 60 days
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Additionally, wait time standards include: - Arrangements to assure coverage for members after-hours
- Patients should be seen within 30 minutes of their appointment time
- The hours of operations offered to all members should be the same regardless of their coverage
- Telephone calls from patients regarding active clinical problems and received during routine office hours should be returned within the hour when clinically appropriate, or on a same day basis otherwise
- Telephone calls from patients regarding routine administrative requests should be returned within 2 business days
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Update: Neighborhood Care Circle
NHP recently launched Neighborhood Care Circle, a new clinical program to address the complex needs of critically at-risk members who account for a large percentage of emergency room visits, lengthy hospital stays, and other acute interventions that contribute to the rising cost of health care. NHP estimates that less than 1 percent of its members are responsible for as much as 20 percent of health care spending. Partnering with Community ServingsNHP has partnered with Community Servings to offer medically tailored home delivered meals within the community to eligible members in the Neighborhood Care Circle program. This service is being offered in order to meet the needs of high-risk members in need of nutrition that they may have no other way of obtaining it. By providing adequate nutrition to members during a time of crisis, such as severe illness or significant social and emotional needs, we hope to minimize the ill effects of poor nutrition on this population. Eligible members will be selected based on program criteria such as medical and social needs. Partnering with Integra ServiceConnectNHP has partnered with Integra ServiceConnect to support the Neighborhood Care Circle program. Integra ServiceConnect works with vulnerable members that may not be reached with regular phone calls and mailings. Specially trained non-clinical Community Coordinators are hired from within the member neighborhoods to empower, educate and assist members in navigating the health care system. Integra ServiceConnect staff work face-to-face with members, collaborate with members' providers to improve the coordination of care and treatment plan adherence, and are available 24/7.
How Can I Help?
You may hear from one of the Neighborhood Care Circle team members when we're trying to reach one of your patients. With your support in engaging and connecting us to your patient, we can help them reach their care plan goals and improve their quality of life.
In addition, this program is designed to support members and complement the service you deliver by assisting with the coordination of their appointments when necessary. For example, we may contact you on behalf of the member to schedule appointments or identify/remove obstacles that impact the adherence to attending a scheduled appointment (such as transportation challenges).
Click Here to find out more about Neighborhood Care Circle.
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Nutrition, Physical Activity, and Obesity Prevention Worksheet: A New Tool For Providers & Members
MassHealth asked us to create a tool to boost BMI reporting and help initiate nutrition and physical activity counseling with patients.The tools we created-provider/patient worksheets targeted to adults, children, and teens-are the result of research and interviews in the field we conducted with nutrition counseling experts working in hospitals and community health centers around Boston. Beth Klos, RD, LDN, Brigham and Women's Hospital, was one provider who gave us great insight into how to best raise the topic with patients. She says, "I find that some patients I meet with express feeling bad about their body, food choices, or weight. Many feel hopeless because commercial diets have not worked for them. Some have been hurt by comments about their weight, and find it a difficult topic about which to open up ." "Acknowledging these realties can be the first step to patients making progress and trusting healthcare providers with the history related to their nutrition," says Klos. Dr. Allison Brown, Medical Director of the Let's Get Movin' program at East Boston Neighborhood Health Center (EBNHC) was able to test these materials in her own practice, "We at EBNHC have enjoyed using these colorful and educational handouts to discuss wellness behaviors with our families. The simple 5210 messaging, food preparation tips, and physical activity advice provided are a great resource for families to take home and use." Here are some best practices contained in these materials. Tips for talking with patients about BMI - Meet the person where they are: Mining who they are is key to opening the conversation.
- Start with a question: Is there any way that weight affects your health?
- Use motivational interviewing technique: Empower patients to make positive changes.
- Use a positive approach: Avoid body-shaming or choice-shaming approaches.
Tips for talking with parents and young patients - Follow the 5210 rule every day: 5 or more fruits and vegetables, 2 hour or less recreational screen time, 1 hour or more of physical activity, 0 sugary drinks, and drink more water.
- Involve the parents: Parents are most helpful when they role-model healthy behaviors. We created Tips for mom and dad, suggestions for fun activities, and healthy, kid-friendly recipes
- Focus goal-setting on food and exercise choices: Set your patients up for success.
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Update: MassHealth Perinatal Screening (S3005)
After a delay to the implementation of applying reimbursement for the perinatal screening code S3005, MassHealth announced that S3005 will be payable effective for dates of service starting on 5/16/16. To align with MassHealth, NHP will also reimburse S3005 for MassHealth members for dates of service starting on 5/16/16. S3005 remains non-reimbursable for Commercial and Qualified Health Plan members.
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Several Trividia Blood Glucose Test Strips Have Been Recalled
On July 1, 2016, Trividia Health issued a voluntary recall of various TRUEread®, TRUEbalance®, TRUEtrack® and TRUEtest® blood glucose test strips. This recall was issued because some test strips vials may be open inside the sealed boxes. Test strip vials that remain open for long periods of time may provide incorrect low blood glucose results. Neighborhood Health Plan (NHP) has notified members who may be affected by this recall. Trividia is working with Stericyle to collect and replace the recalled test strips at no cost to patients. To see if their test strips were affected and to arrange for any recalled test strips to be returned and replaced, patients can call Stericycle toll-free at 888-835-2723. These members were also advised to contact you with any health concerns or to request a new prescription. If you have any questions or need more information about this recall, please call Trividia Health toll-free at 1-800-342-7226 or visit http://trividiahealth.com/product-notice.
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Medical Policy Updates
The following medical policy updates include:
- Scleral Lens (All Products) - effective 8/1/16 - Annual review without substantial changes in medically necessary indicators. References updated.
- Hearing Devices (All Products) - effective 8/1/16 - Annual review without substantial changes in medically necessary indicators. References updated.
- Non-Emergency Medically Necessary Transportation (Commercial and Qualified Health Plans) - effective 10/1/16 - New medical policy to describe the guidelines NHP utilizes to determine medical necessity.
Click Here to view all medical policies.
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Payment Policy Updates
The following payment policies have been revised:
- Imaging Services - effective 8/1/16
- Laboratory and Pathology Services - effective 8/1/16
Click Here to view all payment policies.
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Hepatitis C Virus Treatment
To align with MassHealth and industry standards, NHP will be lifting the liver severity criteria for treatment of the Hepatitis C virus effective August 1, 2016. This change applies to all NHP product lines including MassHealth, Commercial, and Health Connector Plans. Hepatitis C drugs will continue to require prior authorization to support regulatory reporting and data collection requirements. This includes the reporting of the following metrics to MassHealth: liver fibrosis, SVR12, viral load, and genotype. There are no changes to NHP's formulary or drug copayments. As always, we will continue to review and evaluate our formulary on an ongoing basis. To view all drug-specific information, you can access NHP's Drug Look-Up tool.
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Claims Enhancement Reminder
To enhance your experience with the claims process, NHP looks to implement initiatives that are designed to reduce manual interventions and support timely claims processing. Beginning in 2015, NHP started to move certain claim edits from post-payment to pre-payment in order to reduce the overall number of claim adjustments after you receive payment. With the success of this ongoing work, we are excited to continue to identify and implement new pre-payment edits as well as explore other opportunities to improve your claims processing experience.
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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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