December 2016
nhp.org/provider
Provider News 
  OpenEnrollment
2017 MA Health Connector Open Enrollment   
  
From November 1, 2016 through January 31, 2017, Massachusetts Health Connector members can shop for their 2017 health care coverage. We encourage all members to consider their options and select coverage as soon as possible to ensure no breaks in coverage. For members with coverage starting on January 1, 2017, the first premium must be paid by December 23, 2016.
 
For enrollment support, your patients can contact the Health Connector at 1-877-623-6765.

As a reminder, the patient eligibility you have on file can change. To ensure you have the latest eligibility information, please remember to verify health plan coverage for each patient visit. For NHP members, you can use NHPNet to verify member eligibility, member benefits, and that the appropriate referrals/authorizations are in place.  
 
For those members who are considering a change to their health plan, Click Here to view a useful checklist that we mailed to members in November. 
 
  Chiro
Chiropractic Services Updates   
  
NHP recently updated the Chiropractic Services medical policy. You can access this policy on nhp.org/provider.

The following updates will apply to NHP Commercial and Qualified Health Plan (QHP) member plans with benefit years renewing on or after January 1, 2017:
  • Effective January 1, 2017, Commercial and QHP plans with a chiropractic benefit will have an unlimited chiropractic visit benefit upon renewal. Commercial and QHP plans will continue to follow their current allowed benefit limit until their 2017 renewal date. Once the plan renews, there will be no chiropractic visit benefit limit. As the renewal date can vary by plan, it is important to always verify the member's eligibility renewal date and benefit information on NHPNet, the secure provider portal. You can register for NHPNet and access available user guides on nhpnet.org.
  • Starting February 1, 2017, all plans with an unlimited chiropractic visit benefit will require prior authorization for visits beyond 20 visits. Visits that occur before the plan renewal date will not count towards the 20 visits and will not be subject to the prior authorization requirement. For plans that renew in January, visits that occur in January and after the renewal date will count towards the 20 visits. You will be able to submit prior authorization request through NHPNet. We will provide more information over the next several months.
There are no changes to the chiropractic benefit for MassHealth members. NHP MassHealth members will continue to have a benefit limit of 20 chiropractic visits within the benefit period (October 1-September 30).

  Somerville
NHP Is Moving to Assembly Row, Somerville  
  
As a reminder, NHP will move to a new location in Assembly Row, Somerville in January. Our new corporate address will be:

Neighborhood Health Plan
399 Revolution Drive, Suite 810
Somerville, MA 02145

Most departmental phone and fax numbers will remain the same. However, all phone numbers to individual NHP employees will be changing.

Starting 1/1/17, mail should be directed to the Somerville address as mail to the Boston address will be stopped. To ensure timely delivery, you must include the specific department suite number with all correspondence.

Here is the contact information for departments you may regularly correspond with:

Provider Service
  • Email (general inquiries): providerservice@nhp.org
  • Email (NHPNet inquiries): prweb@nhp.org
  • Phone: 855-444-4647, Monday through Friday, 8:00 AM to 6:00 PM

Provider Enrollment & Credentialing
  • Email: pec@nhp.org
  • Fax: 617-526-1982
  • Suite# (mail): 940

Authorizations, Referrals, and Clinical
  • Web: nhpnet.org
  • Fax: 617-586-1700
  • Suite# (mail): 920

Claims  
  • Original Claims:
    • NHP recommends the electronic submission of all original claims
    • Paper claims: P.O. Box 853908, Richardson, TX 75085-3908 
  • Claims adjustments/appeals/correspondence:
    • Fax: 617-526-1902
    • Suite# (mail): 940
  auth
Authorization System Update 
  
In September, NHP implemented enhancements to our authorization intake system. Although most prior authorization requests can be submitted through NHPNet, there are some services that currently must be faxed in. Starting on February 1, 2017, NHP will implement another enhancement to allow prior authorization requests for the following services to be submitted through NHPNet:
  • Home Infusion
  • Chiropractic
  • Outpatient Infusion
  • Infertility (IVF)
  • Pain Management

NHP will no longer accept faxed requests for these services after 2/1/17. Additional information on user guides and training opportunities will be shared in the coming weeks.   

 

  eyemed
NHP Partners with EyeMed for Pediatric Vision Benefits 
  
Beginning on January 1, 2017, NHP commercial and QHP individual/families and small group plans will include pediatric vision benefits powered by EyeMed. Individuals/families and small groups will transition to the new plans upon their renewal date.  Along with ACA required FEDVIP vision benefits for children up to age 19 only, members will have access to one of the nation's largest networks of independent and retail providers. To search for a provider in EyeMed's network, members can visit nhp.org/find-a-doctor.

  delta
Delta Dental to Provide Pediatric Dental Benefits in 2017 
  
Starting on January 1, 2017, NHP will partner with Delta DentalĀ® of Massachusetts to provide pediatric dental benefit for NHP members.  Delta Dental has an extensive provider network and has NHP's shared focus of preventive care and customer service. To search for a provider in Delta Dental's network, members can visit nhp.org/find-a-doctor
  feeschedule
NHP Fee Schedule Updates Reminder 
  
In June, NHP shared plans to update our fee schedules to reflect current industry guidelines. Here are the latest updates: 

NHP MassHealth Reimbursement
 
As a reminder, for services rendered to NHP's MassHealth members, the reimbursement of codes aligns with MassHealth reimbursement guidelines. As part of our ongoing fee schedule reviews and updates, codes identified as not payable under MassHealth reimbursement guidelines will be removed. For MassHealth reimbursement information, please refer to sub-chapter 6 in MassHealth's Provider Manuals: 

Drug Fee Schedules  

On October 1, 2016, CMS implemented updates to their ASP drug pricing. To align with the CMS updates, NHP is adjusting our drug fee schedules accordingly effective October 1, 2016. Through an ongoing review process of the latest industry guidelines, NHP plans to update the drug fee schedules bi-annually (January 1 and October 1).     

  incentive
MassHealth Hospital Incentive Program
  
MassHealth recently announced a hospital incentive program for the MCO contract year (October 1, 2016-September 30, 2017). Hospitals must report certain performance measures, including information related to access to medical and diagnostic equipment for MassHealth members with disabilities. If the performance measures are met, MCOs will distribute incentive payments in monthly installments (the total payment to each hospital is determined by MassHealth). For more information on the incentive program, refer to MassHealth's provider bulletin.

  HEDIS
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 2017 and end in May 2017. 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 FAQ. 

  Survey
Provider Surveys  
  
Provider Directory Survey
In November, NHP conducted an annual assessment to validate the accuracy of data in the provider directory. Incorrect data contribute to patient dissatisfaction and can result in claims payment problems. Providers were asked to verify their information on the provider directory and submit any changes to NHP on the Standardized Provider Information Change Form.

Specialist Wait Time Survey
At Neighborhood Health Plan, we find it important to understand our members' wait time experiences at provider offices. In November, we asked specialty practice sites to complete a survey so we could improve our understanding of member wait time experiences as well as supply required reporting information to NCQA.

Thank you to all participants of these surveys. Responses for each survey were entered into raffle drawings. Congratulations to Denise of Bay State Physical Therapy and Audrey O'Keefe of Mass General Hospital Cardiac Surgery for each winning a Kindle Fire!

  BH
Substance Use Disorders and Medication Assisted Treatment for Opiates 
  
Medication Assisted Treatment (MAT) is the use of medications, in addition to counseling, cognitive behavioral therapies, and recovery support services, to provide a comprehensive approach to the treatment of substance use disorders. Beacon Health Options, NHP's behavioral health benefit manager, has developed this training presentation to provide an overview of substance use disorders and MAT for opiates.  
  hereforyou
Here-for-YouSM Program  
  
Overview
Neighborhood Health Plan (NHP), Beacon Health Options (Beacon), and participating community-based mental health agencies, have collaborated to develop an integrated care coordination model designed to support identified patients who are highly impacted by serious mental illness (SMI) and complex medical concerns. The Here-for-YouSM (HFY) program provides a fully coordinated, person-centered focus to meeting the complex functional and health care needs of patients with co-morbid behavioral and medical conditions. 
 
This program works to engage identified patients by targeting the most immediate and crucial needs such as housing, food, and transportation, as well as providing linkages to medical, community-based, and behavioral health services. The program is designed to improve the physical and mental well-being of these members by providing:
  • A tailored approach to care management and coordination
  • An integrated team to build an individualized, comprehensive, and person-centered care coordination plan
  • A strengths-based and culturally/linguistically appropriate approach by qualified professionals who have access and support from a wider network of clinical support, resources, and technical assistance
PROGRAM OBJECTIVES
  • To improve patient well-being and quality of life through targeted interventions and a person-centered focus
  • To improve health outcomes and reduce emergency room and acute hospital admissions/readmissions through enhanced communication between behavioral and physical health care providers resulting in increased coordination/transitions of care for patients
  • To improve adherence with Primary Care treatment and encourage the continued use of preventive and screening programs which decrease the occurrence, emergence, or worsening of behavioral health disorders
  • To develop collaborative relationships with in-network practitioners resulting in increased satisfaction and adherence to evidence-based guidelines and standards of care
WHAT DOES THIS MEAN FOR MY PRACTICE?
  • Care coordinators help to integrate medical needs with behavioral health needs and provide support around psychosocial needs (housing application, food stamps, SSDI, etc.)
  • You may get calls and/or signed releases of information from Here-for-Yousm Care Coordinators looking to discuss a patient's care
  evicore
Update: Redirecting to eviCore.com   
 
NHP partners with eviCore Healthcare for utilization management of high-tech radiololgy, non-OB ultrasounds, cardiac imaging, molecular & genetic testing, and radiation therapy.

In 2014, CareCore National and MedS olutions merged to form eviCore HealthCare. Beginning December 3, 2016, users visiting the legacy CareCore National ( carecorenational.com ) and MedSolutions ( medsolutions.com ) sites will be automatically redirected to the eviCore.com site. On eviCore.com, you will have access to eviCore's provider portals through an integrated login page.

Important: If you are currently using the MedSolutions 1.0 Portal (medsolutionsonline.com), you will need to register through the eviCore.com login feature to gain access to the 2.0 Portal.
 

 

  pharmacy
Pharmacy Benefit Programs 
 
Visit our webpage at nhp.org/provider for the most up-to-date information about the NHP Pharmacy programs, covered medications and the current medical necessity criteria. Pharmacy programs include:

 

Excluded Medication: A medication which is considered to be excluded from the pharmacy benefit.

 

Pharmacy and Therapeutics Committee: This Committee is chaired by the NHP Medical Director responsible for pharmacy and is composed of practicing pharmacists and practicing providers with varying specialties, including behavioral health, internal medicine and pediatrics. It meets regularly throughout the year, no less frequently than quarterly.

 

Prior Authorization: A pharmacy program which limits access to a medication by establishing criteria for appropriate use of a medication. These criteria must be met and documentation sent to NHP before the medication will be covered. Prior authorization is also required for exception to NHP's mandatory generic medication pharmacy benefit.

 

Quantity Limit: A pharmacy program that limits the number of units per time period for a specific medication based on recommended doses.

 

Step Therapy: A pharmacy program which allows patients who meet criteria to have coverage for their prescription adjudicate without review based on available medication history.

 

Mandatory Generic: A pharmacy program which requires a trial of an FDA approved generic substitution for a brand name medication, if it is available.

 

Tier Placement: A pharmacy program that places medications in one of three co-payment tiers for NHP benefit plans with a three tier pharmacy benefit.

 

Therapeutic Interchange/Substitution:  A pharmacy program that involves the dispensing of a chemically different drug, considered therapeutically equivalent, i.e., will achieve the same outcome, in place of a drug originally prescribed by a physician. The drugs are not generically equivalent. Therapeutic substitutions are done in accordance with procedures and protocols set up and approved by physicians in advance. Therefore, the pharmacist would not have to seek the prescribing physician's approval for each interchange.

 

  nhporg
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 businesses 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 [combine]
  • 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
  • Interpreter Services
The latest version of NHP's provider manual is accessible via nhp.org/provider . If you are unable to access the provider manual online, you may contact provider service at 1-855-444-4647 for alternative access.
 
  drg
NHP to Implement DRG and EAPG Payment Methodologies in 2017 
 
To align with industry practice, NHP will look to begin implementation of industry standard DRG and EAPG payment methodologies in 2017. We will provide more information over the next several months.  

 

  mpr
Medical Policy Updates 
 
The following are medical policy updates effective 12/1/16:
  • Definition of Skilled Care (All Products) - Annual review without substantial changes in medically necessary indicators. References updated.
  • Acupuncture (All Products) - Annual review without substantial changes in medically necessary indicators. References updated.
  • Out of Network Providers (All Products) - Annual review without substantial changes in medically necessary indicators. References updated.

The following are medical policy updates effective 2/1/17:

  • Neuromodulation for Overactive Bladder (All Products) - New medical policy describing the guidelines NHP utilizes to determine the medical appropriateness of neuromodulation, including percutaneous tibial nerve stimulation (PTNS), trial of sacral nerve neuromodulation, and permanent implantation of sacral nerve stimulation (SNS) to treat overactive bladder disorder.

Click Here to view all medical policies.  

 


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.  

 
Helen Connaughton
Director of Provider Relations  
Neighborhood Health Plan