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The Centers for Medicare and Medicaid Services (CMS) Acute Hospital Care at Home program helps to increase hospital capacity and improve resource allocation during the COVID-19 national public health emergency. This is an expansion of the Hospital Without Walls program. The Hospital Without Walls program allowed hospitals to provide services in locations beyond existing facilities.
In November 2020 and as part of Acute Hospital Care at Home, CMS waived a previous Medicare Conditions of Participation requirement. This waiver allows qualifying hospitals to receive inpatient payment for providing acute-level services to Medicare beneficiaries in their homes.
CMS Waiver Process
CMS is accepting waiver requests to waive §482.23(b) and (b)(1) of the Hospital Conditions of Participation, requiring nursing services to be provided on-premises 24 hours a day, 7 days a week, and the immediate availability of a registered nurse (RN) for care of any patient. Here are the guidelines on the waiver criteria and process.
CMS divides the waiver requests into 2 categories based on a hospital’s prior experience:
As of July 27, 2022 CMS has approved 245 hospitals and 110 health systems in 36 states to participate in the Acute Hospital Care at Home program. Refer to the complete list of approved hospitals and health systems to learn more.
Please note: Every hospital certified to provide care to Medicare patients has a unique CMS Certification Number (CCN). Any hospital seeking to provide Acute Hospital Care at Home must submit the waiver request under its unique certification number. For example, if a hospital system includes 10 hospitals, but only 4 of those hospitals admit patients who use Acute Hospital Care at Home services, 4 separate waiver requests must be submitted.
Qualifying Claim / Billing Requirements
Health New England requirements: Health New England will accept qualifying1 claims for the approved plans until further notice or through the duration of the national public health emergency. Health New England will deny any claims received for Plans not approved under this program.
Approved Plan(s) for the CMS Acute Hospital Care at Home Program.
Not approved Plan(s) for the CMS Acute Hospital Care at Home Program:
Health New England Claim Requirements:
When submitting claims to Health New England, please use the following guidelines:
CMS requirements: To meet the standards of a qualifying Medicare Advantage claim for the Acute Hospital Care at Home program, facilities must complete the waiver process and have received the waiver from CMS.
1A qualifying claim requires CMS waiver requirements to be met, along with the following criteria:
ACO Home Care Partnership: With the Accountable Care Organization, there are certain guidelines to follow when requesting services, how to submit requests and billing procedures. In fact, the type of professional services allowed is based on the degree of skills as it relates to the medical necessity of the member. Health New England is here to help you understand and partner for the care of our members. Below is information necessary for you to know.
Requirements and Guidelines: Reference the ACO Home Care Partnership Booklet to learn more about authorization requirements and guidelines around type of services and payment guidelines.
Commonly Used Managed Codes and Descriptions: Reference the Home Care Service Code Description Card to understand the best practices with the various codes used for each services.
Frequently Asked Questions (Coming Soon)
Health New England is partnering with Vital Decisions, a company specializing in providing services to individuals and their families who are experiencing advanced illness. This partnership allows access to Vital Decisions’ Living Well Program.
Vital Decisions’ specially trained professionals will work with our Fully Funded Commercial, Medicare and BeHealthy Partnership® members who are experiencing difficult healthcare situations. The Vital Decisions’ team members work, through a series of telephone or video sessions, to help educate, discuss, and work through the important topics of advance care and life planning. Their role is to help individuals identify their quality of life preferences and values and help them to actively and effectively communicate their priorities to family and physicians. This will help to ensure that more effective shared decision-making processes occur and will help to align decisions with the individual’s preferences and priorities.
Vital Decisions’ staff will at no time interfere with the physician-patient relationship, provide medical advice, or provide an opinion regarding the care plan or team in place. Experience has demonstrated that the program enhances communication and the overall patient-physician relationship.
At Health New England, we want our members to know there are alternative methods for managing pain than just simply using medication. While we understand the need for some medication, we want providers to be aware of the various options our plans offer for pain treatment.
We hope the following information will support discussions with your patients, who are also Health New England commercial plan members, about their options.
Pain Management Alternatives offered by Health New England:*
*Coverage and/or number of visits may vary depending on plan type.
Evicore Healthcare, LLC, a national leader in integrated, innovative intelligent care management solutions, partners with Health New England in the management of authorizations and reporting for all our business lines.The services they provide are:
For more information about evicore, please go to www.evicore.com
To access the commonly used managed codes for genetic lab, sleep study program or high cost imaging, log on to the Evicore Portal.
The below chart provides guidance on when services received an approved authorization from eviCore and when it is recommended for those services to be rendered:
Northwood, Inc. (Northwood), a durable medical equipment benefit manager (DBM) will manage a full range of services and provider types in order to administer DMEPOS benefit for Health New England’s Commercial, Medicare Advantage and Medicaid members.
The services they will provide are as follows:
The following provides the various provider types Northwood will manage and those exceptions where Health New England will review your request. In both situations, Northwood’s criteria is used to review for medical necessity. Please reference the medical policies below for each product line. For authorization forms, please go to Northwood’s website and follow the link. For those exceptions where Health New England will help, please go to https://healthnewengland.org/forms and click “Clinical Request Forms.” For additional information such as Northwood’s provider manual for Health New England, frequently asked questions or provider orientation, please visit Northwood's website.
Provider types managed by Northwood vs. Health New England
Northwood managed codes (effective 4/1/23)
Northwood commercial/Medicare medical
Northwood Medicaid medical policies
HIPAA x12 standards, version 5010, is a new standard that regulates the electronic transmission of specific health care transactions. Covered entities – health plans, health care clearinghouses, and health care providers - adopted HIPAA5010 standards on January 1, 2012.
Health New England remains committed to working with our trading partners still utilizing 4010 standards to support the migration from HIPAA4010 to HIPAA5010.
To help make this transition as smooth as possible, we have designated a contact person for each transaction type. If you have any questions or identify any issues as you go about your testing, please contact us at HIPAA5010@hne.com.
An Interactive Voice Response (IVR) is an automated phone system technology that allows for incomingcallers to access information by a voice response system of pre-recorded messages. Health NewEngland’s system will help our providers 24 hours, 7 days a week. If our system is unable to provide youwith the information you need, it will direct you to a live Claims Representative during our normalbusiness hours 8 a.m. – 5 p.m., Monday – Friday.
For additional assistance on using the system, please see the Frequently Asked Questions document below.
FAQ - Claim Status
FAQ - Eligibility
Health New England is partnering with HealthMap Solutions to provide more comprehensive care for Medicare members with Chronic Kidney Disease (CKD) and End Stage Renal disease (ESRD). HealthMap’s Kidney Health Management (KHM) program integrates into your existing practice workflow to reduce additional office work, while enhancing communication. HealthMap offers the best kidney health solution that will support you in providing care for your patients.
Our members identified as being at risk for CKD stage 3 and higher are included in the KHM program. HealthMap will contact you to schedule an overview of the program and to collaborate as you manage your patients with CKD and ESRD.
Individualized patient recommendations are addressed in two ways to achieve best outcomes:
The care navigation team provides complex care coordination services to support health care needs between office visits. Care navigation supports the patient’s overall care and focuses on identifying and removing barriers that prevent a patient from achieving their optimal health.
Learn more at healthmapsolutions.com. For additional information, review this HealthMap provider packet or call the Health New England dedicated line at (800) 985-9208 to schedule an orientation or to refer patients.
Beginning January 1, 2022, Health New England will initiate a site of service program review as part of our prior authorization process for a select group of medications. Health New England members between the ages of 18 and 64 will be required to shift their care from an outpatient hospital setting to home infusion. This change is to ensure Health New England members receive appropriate and safe administration of infusion medications in the most cost-effective location. Health New England patients receiving infusions in the physician’s office will not be affected by this policy.
As a result of the COVID-19 pandemic, a growing number of individuals and families across Massachusetts are facing food insecurity, many for the first time. MassHealth, in partnership with other state agencies and food non-profit organizations, has developed a simple guide that your member-facing staff or your network providers can use to help identify MassHealth members who need food assistance and connect them to resources in the community. Those food assistance resources can provide your members with immediate access to food, as well as recurring financial support for the purchase of food.
ProgenyHealth, a national company dedicated to population health management for infants admitted to the neonatal intensive care unit (NICU) or special care nursery (SCN), Partners with Health New England on the care management and utilization management for medically complex newborns in our commercial and Medicaid business lines. their care coordination team includes neonatologists, pediatricians, nurses, and social workers. this team has a deep understanding of the evidence-based protocol needed to support outcomes and supports families from initial NICU or SCN admission to first year of life.
The prior authorization comes into Health New England as it does today. ProgenyHealth will then follow the infant from initial admission into the NICU (for our commercial member or effective date added to BeHealthy Partnership) or SCN until the first year of life*. Health New England resumes care management/utilization management after the first year of life.
*ProgenyHealth will follow any readmissions through the 1st year of life for level of care.
For additional information on ProgenyHealth, please visit https://www.progenyhealth.com
The Federal No Surprises Act protects Health New England members from receiving surprise medical bills from providers who are not contracted with Health New England, otherwise known as out-of-network providers. This Act includes requirements associated with transparency of health care cost, more timely validation of provider directory information, and updating member ID cards to include more benefit information.
In addition, our network providers are required to validate the accuracy of our Provider Directory every 90 days. To learn more about provider data, please go to our Provider Manual at https://healthnewengland.org/provider-manual, click “Network Operations” and reference “Administrative Procedures.”
These guidelines establish when Health New England (HNE) must accept non-contract provider appeals. Non-contract providers are providers that are not participating in the HNE Medicare Advantage product but who have provided services to a Health New England Medicare Advantage member. If HNE Medicare Advantage denies a request for payment, in whole or in part, from a non-contract provider, HNE Medicare Advantage shall notify the non-contract provider of the specific reason for the denial and shall provide a description of the appeals process.
When a non-contract provider submits an appeal of a denial of payment, HNE Medicare Advantage must verify the following information prior to processing the appeal:
Maximus Federal Services, Inc.
Medicare Managed Care & Pace Reconsideration Project
3750 Monroe Avenue, Suite 702
Pittsford, NY 14534-1302
Maximus Federal Services, Inc.
Medicare Managed Care & Pace Reconsideration Project
3750 Monroe Avenue, Suite 702
1 See the Medicare Managed Care Manual , Chapter 13, “Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPS), (collectively referred to as Medicare health plans),” Sections 40.2.3 and 60.1.1.
These policies apply to all in-network and out-of-network1 providers requesting to have Health New England (HNE) review their original claim denial and ask for reconsideration.
1Health New England follows, outside of these policies, the guidelines and regulations of The Federal No Surprise Act, if applicable to the claims payment.
Health New England is excited to announce a new, cutting-edge pharmacy transparency service called Rx Savings Solutions. This new service partner helps patients/members find the lowest-cost prescription drug, according to their own health plan. It empowers both providers and patients with the information needed to select the most cost-effective, yet therapeutically-conscious, prescription medication for the patient. The patented software analyzes prescription claims and considers all possible clinical options to save its users money on prescriptions, all within the user’s specific plan design.
Rx Savings Solutions may reach out to providers on behalf of our commercial members by fax. See sample fax .pdf below for reference.
Questions: please reach out to the Rx Savings Solutions pharmacy support team at (800) 268-4476 or email firstname.lastname@example.org, Monday-Friday, from 8 a.m. to 9 p.m. ET. For additional information, visit www.healthnewengland.org/rxss.
When a Health New England member needs rehabilitation services for a serious or persistent health issue or skilled therapy, a Skilled Nursing Facility (SNF) can provide short-term care. This booklet will help guide the Skilled Nursing Facility through Health New England’s process to ensure a smooth transition for our member.
Requirements and guidelines: reference guide for Skilled Nursing and Rehabilitation facilities to learn more about clinical criteria, admission, initial & concurrent reviews, discharge, guidelines on product lines and more. in addition, reference our skilled nursing payment policy for more information on payment guidelines.