PROVIDER MANUAL FOR NEW HAMPSHIRE MINUTEMAN HEALTH PLANS

Transcription

1 PROVIDER MANUAL FOR NEW HAMPSHIRE MINUTEMAN HEALTH PLANS

2 TABLE OF CONTENTS INTRODUCTION... 5 MINUTEMAN HEALTH PROVIDER QUICK REFERENCE... 7 Prvider Web Prtal at MinutemanHealthDirect.rg... 7 Member Eligibility and Identificatin Cards... 8 ADMINISTRATIVE PROCEDURES... 9 Prvider Recrd Changes... 9 Prvider Address and Telephne Number Changes... 9 Physician Participatin in PHOs r Medical Grups Physician Primary Hspital Affiliatin Changes/Additinal Hspital Affiliatins Prvider Tax Identificatin Number Changes Prvider Cverage Arrangements Member Assignment t Primary Care Panels PCP Panel Status Changes Remving a Member frm a PCP s Panel MINUTEMAN PRODUCTS AND BENEFITS HMO Plans Pint f Service (POS)Plans Preventive Care Emergency and Urgent Care Obstetrical and Gyneclgical Services Rutine Visin Exam Chirpractic Benefit Durable Medical Equipment (DME) Labratry Services Minuteman Physician Office Allwable Lab Tests Behaviral Health Services Substance Abuse Services Miscellaneus Services including Pain Management, Bifeedback and Neurpsychlgical Testing Pediatric Dental Services PHARMACY SERVICES UTILIZATION MANAGEMENT Prir Authrizatin Prcess Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 2 f 69

3 New Technlgy and Prcedures UM Decisin Prcess Physician Reviewers Care Management Cmplex Case Management Chrnic Cnditin Management Health Infrmatin Line (HIL) Behaviral Health Diagnstic Imaging Management Prgram Accreditatin Requirements fr Advanced Diagnstic Imaging Facilities Clinical Transitin Prgram Apprpriateness f Care Statement Medical Technlgy Assessment Prgram HIPAA Privacy Requirements and Patient Infrmatin Needed fr Utilizatin Management, Case Management and Care Crdinatin CLAIMS SUBMISSION AND REIMBURSEMENT Scpe f Services Claims Prcedure Claims Xten Edits Imprtant Infrmatin Regarding All Claims Paper Claims Clean Claim Requirements Minuteman Prvider Cllectin Plicy Crdinatin f Benefits Explanatin f Payment (EOP) DME Billing Guidelines and Prcedures Minuteman s Vaccine Plicy HEDIS reprts fr prviders PROVIDER APPEAL GUIDELINES MINUTEMAN CLINICAL GUIDELINES AND STANDARDS Clinical Guidelines and Standards Medical Recrd Standards and Reviews Credentialing/Recredentialing Prvider Review and Crrective Actin Plicy Serius Reprtable Events and Never Events HEDIS NCQA Accreditatin Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 3 f 69

4 MINUTEMAN CORPORATE COMPLIANCE PROGRAM (INCLUDING FRAUD, WASTE, AND ABUSE PREVENTION PROGRAM) Cmpliance Statement and Cde f Cnduct Reprting Yur Cncerns Privacy and Security Prgram Fraud, Waste, and Abuse Preventin Prgram Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 4 f 69

5 INTRODUCTION Minuteman Health, Inc. ( is a member gverned, nn prfit health maintenance rganizatin (HMO) cmmitted t remving inefficiencies frm tday s health insurance system t prvide high quality care, cut administrative csts and reduce premiums fr individuals and businesses in Massachusetts and New Hampshire. Minuteman ffers HMO plans in New Hampshire that utilize the Minuteman New Hampshire netwrk, as well as the Minuteman Massachusetts netwrk, as In Plan Prviders. Minuteman als ffers POS plans in New Hampshire which utilize the tw afrementined netwrks as In Plan Preferred Prviders, and the natinal First Health netwrk as In Plan Nn Preferred Prviders. Please see the Minuteman Prducts and Benefits sectin f this manual fr mre infrmatin, and refer t the prvider directries at fr a current listing f In Plan Prviders. The New Hampshire (NH) prvider cmmunity has a wide variety f clinicians including but nt limited t: stepathic physicians, chirpractrs, pdiatrists, nurse practitiners, ptmetrists, licensed prfessinal midwifes, physical therapists, and behaviral health clinicians, including psychiatrists, licensed psychlgists, licensed pastral psychtherapists, advanced practice psychiatric nurses, licensed mental health cunselrs, licensed alchl and drug cunselrs, licensed family therapists, licensed clinical scial wrkers and licensed dctrs f naturpathic medicine. Minuteman s directly cntracted NH netwrk is cmprised f these and ther clinicians wh have decided t actively participate in ur cst effective netwrk. All f these cntracted clinicians, may practice withut discriminatin and within the scpe f their practice as defined by New Hampshire law. They must hwever abide by Minuteman's NH cverage decisins, which are described in Minuteman s plicies and prcedures, including but nt limited t Minuteman Member benefit structures, medical plicies, Utilizatin Management (UM) plicies, cntractual and payment plicies. Minuteman als cntracts with the natinal First Health netwrk fr ur POS prducts, DentaQuest fr pediatric dental benefits available under ur Patrit r ff exchange nly prducts, and OptumRx (frmerly knwn as Catamaran) fr pharmacy benefits. This Prvider Manual cntains infrmatin abut the guidelines and prcedures which shuld be fllwed by prviders when rendering medical service t Minuteman members. Sme f the guidelines and prcedures in this Manual are based n requirements f State and Federal law as well as accrediting rganizatins. Thus, the guidelines and prcedures are subject t change if the requirements f the law r accrediting rganizatins change. Minuteman will ntify prviders in writing f mdificatins t this Manual that have a substantial impact n prvider rights r respnsibilities at least 60 days prir t the effective date f such mdificatins. Where there is a cnflict between this editin f the Manual and a subsequent ntificatin f a mdificatin t a plicy r prcedure related t a change in the law, the infrmatin in the subsequent ntificatin shall prevail. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 5 f 69

6 Other (nn substantial) changes will be updated nline with ntice including an electrnic list f changes and links t the amended sectins, sent t the designated persn in each prvider rganizatin. If yu have questins r suggestins regarding the infrmatin in this Prvider Manual r wish t btain a paper cpy f the Manual, please cntact Minuteman Prvider Services at Representatives are available Mnday Friday frm 9: 00AM t 12:00PM and 1:00PM 3:00PM. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 6 f 69

7 MINUTEMAN HEALTH PROVIDER QUICK REFERENCE Prvider Web Prtal at MinutemanHealthDirect.rg Prviders can view up t date infrmatin n line by using the Minuteman prvider prtal, including: Member eligibility, benefits infrmatin, and cpay amunts Prir authrizatin request(s) Claims status Explanatins f payment Netwrk Prvider/practice rster changes Prviders wh have questins abut this service r are interested in registering fr the Minuteman prvider prtal shuld g t t register. Phne: Prvider Services Phne: (Select Optin 4) Fax/ T reach these departments within Minuteman Prvider Services: Dial , select Optin 4, then the fllwing ptins: Eligibility & Benefits 1 Prvider Claims Servicing (Claims Status & Billing) 2 Minuteman Health Services (Prir Authrizatin and UM)* 3 Fr all ther issues 4 *Fr Diagnstic Imaging Prir Authrizatin: Cntact evicre/medslutins at *Fr Rx Prir Authrizatin: Cntact OptumRx (frmerly knwn as Catamaran) at *Fr Pediatric Dental Claims/Benefits: Cntact DentaQuest at r dentaquest.cm Department Fax/ Health Services (Prir Authrizatin) Prvider Appeals Member Services Prvider Relatins (Cntracting, Credentialing & Enrllment) r prviders@prvidernetwrkalliance.cm Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 7 f 69

8 Mailing Address Infrmatin (including paper claims): Crrespndence Claims Minuteman Health, Inc. Minuteman Health P. O. Bx c/ Health New England Bstn, MA One Mnarch Place, Suite 1500 Springfield, MA Minuteman Payer ID fr EDI Claims Submissin: Member Eligibility and Identificatin Cards Minuteman Members are issued an identificatin card (ID card) when they enrll r change plans. Members are instructed t present their ID card when seeking medical services. The ID card alne des nt guarantee eligibility. Yu can verify eligibility and benefits by lgging n t MinutemanHealthDirect.rg. If yu have nt registered already, yu can d s by ging t Refer t the Member s ID card t identify any Member cpayment amunts fr ffice visits, urgent/emergency care, prescriptins, etc. Fr mre detailed infrmatin n members cst sharing and benefits please cntact Prvider Services. The Prvider Netwrk Alliance (PNA) lg is n the back f all ID cards because the Minuteman Health Massachusetts prvider netwrk is cntracted via PNA. The First Health lg is als n the back f all cards since we are using First Health fr ur POS plans and in ther limited circumstances. The In Plan Netwrk Name shwn at the tp f the frnt f the card will display as ne f tw ways fr ur New Hampshire members: Minuteman Health Netwrk NH IND (fr members in individual r nn grup plans) Minuteman Health Netwrk NH GRP (fr member in grup plans) The grup number n the ID Card cntains imprtant infrmatin. Fr ur insured business, the first digit is (Z). Fr ur insured individual and small grup plans, the secnd digit identifies whether the plan is On Exchange (E) r Off Exchange (N), and the third digit identifies an Individual (I) r a Small Grup (G) plan. Fr large grup insured plans, the secnd and third digit will bth be zers. Fr self insured plans, the first and secnd digits will be SZ. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 8 f 69

9 Sample ID card: ADMINISTRATIVE PROCEDURES Prvider Recrd Changes Please ntify Minuteman Prvider Relatins f changes invlving telephne numbers, addresses, hspital affiliatins, tax identificatin numbers, cverage arrangements and panel status. Failure t prvide timely ntice f such changes may result in incnvenience t patients and pssible delays in payment. Mail Minuteman Health, Inc. Attn: Prvider Relatins P.O. Bx Bstn, MA Phne/Fax , select Optin 4 / prviders@prvidernetwrkalliance.cm Prvider Address and Telephne Number Changes Changes f address and telephne number must be cmmunicated t Prvider Relatins, in writing n less than sixty (60) days frm the effective date f the change. When infrming f an address r telephne number change, prviders shuld specify whether the change is fr an ffice address r phne number, billing address r phne number, r bth. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 9 f 69

10 Physician Participatin in PHOs r Medical Grups Physicians that establish r terminate membership(s) in a prvider rganizatin (e.g. PHO, ACO, Medical Grup), r enter int ther arrangements that may affect participatin status must ntify Prvider Relatins, in writing nt less than sixty (60) days prir t the effective date f the change. Such change in status may have an impact n payment terms and cntractual bligatins. The failure f physicians t prperly ntify Minuteman f such change in participatin status may result in delayed, denied r incrrect payments. Physician Primary Hspital Affiliatin Changes/Additinal Hspital Affiliatins If a physician wuld like t add, change r delete his r her primary hspital affiliatin, the request must be submitted n less than sixty (60) days prir t such change. The ntificatin shuld indicate the reasn fr the change and the effective date f the change. Prvider Tax Identificatin Number Changes When a prvider has a change in his r her Federal Tax ID number, Prvider Relatins must be ntified in writing at least sixty (60) days prir t the change. When ntifying Prvider Relatins f the change the fllwing infrmatin must be prvided: New Federal Tax ID number (W 9) The name t which checks shuld be made payable Billing address Billing phne number Effective date f change Prvider Cverage Arrangements Minuteman requires all PCPs t make arrangements fr care fr Members listed n their panels twentyfur hurs a day, seven days a week. When arranging fr cverage, the cvering practitiner will be bund by the PCP's agreement. If a physician des nt prperly maintain cverage arrangements, delayed r incrrect payments may result. Member Assignment t Primary Care Panels Minuteman requires all Members t select a PCP. Only physicians and registered nurse practitiners in primary care specialties (internal medicine, pediatrics and family practice) can be assigned as PCPs. Members may change their PCP either n the Member's request, prvider request under certain circumstances (see belw) r if the patient starts seeing a PCP frm a different prvider grup. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 10 f 69

11 PCP Panel Status Changes PCPs may change their panel status by ntifying Prvider Relatins in writing. PCPs may change the age restrictin placed n their panels and may als change restrictins n accepting new patients. If a change places a greater restrictin n the PCP s panel, the change must be made in cmpliance with the prvider agreement and will be effective thirty (30) days frm the date that Minuteman Prvider Relatins received the request. Any change that reduces r eliminates a restrictin t a PCP s panel will be effective immediately upn receipt f the request. Categries f PCP panel status are described belw: ALL Any Member wh chses this PCP will be added t the PCP s panel, prvided the Member is within the age restrictins that the PCP has prvided t Minuteman Prvider Relatins. EXISTING Only Members wh are patients f this PCP at the time they became Minuteman Members will be added t the PCP s panel. All Minuteman Members are asked if they are an existing patient f the PCP that they have selected. A Member wh answers Yes will be added t the PCP s panel. If the Member answers N, the Member will nt be added t the PCP s panel. The PCP s name will appear in the Minuteman Prvider Directry and under the Accepting New Patients field Has Restrictins will be displayed. CLOSED N Members may be added t this PCP s panel. Neither new nr existing patients will be added t this PCP s panel. PCPs with a clsed panel will nt appear in the Minuteman Prvider Directry. PCPs must nt treat Minuteman Members differently frm nn Minuteman Members with respect t clsed panel status. Remving a Member frm a PCP s Panel The physician patient relatinship is a persnal ne which may becme unacceptable t either party. If this happens, the Member r the PCP may request that a Member be transferred t anther PCP. In rder t remve a Member frm his r her panel, the PCP must send a letter t the Member requesting that the Member chse anther PCP, with a cpy faxed t Minuteman Prvider Relatins. The letter must explain why the PCP is remving the Member frm his r her panel. The PCP may nt request a Member s transfer fr discriminatry reasns, because f the amunt f medical services required r because f a Member s physical r mental cnditin. Once Prvider Relatins receives the letter, the Minuteman Member Services Department will cntact the Member t assist them with selecting a new PCP. Frm the time Minuteman cntacts the Member, the Member will have 30 days t select a new PCP. If they d nt chse a new PCP within 30 days, Minuteman will assign them a new PCP. Minuteman will then send a letter t the Member advising them f the change. PCPs must cntinue t treat the Member during this transitin perid. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 11 f 69

12 Member Rights and Respnsibilities Member Rights Members f MHI have certain rights. These are t: Receive infrmatin n MHI, its services, In Plan Prviders, plicies, prcedures, and Member rights and respnsibilities. MHI will nt release infrmatin that by law may nt be given t Members r any third party. We will nt disclse privileged infrmatin abut In Plan Prviders. Be treated with respect and with recgnitin f the Members dignity and right t privacy. Participate in health care decisins with their dctr r ther health care prviders. Expect that their dctr r ther health care prviders will fully and penly discuss apprpriate, medically necessary treatment ptins, regardless f the cst r benefit cverage. It des nt mean that MHI cvers all treatment ptins. If Members are unsure abut cverage, please cntact the Member Services team. Cntact us with a grievance r cmplaint abut MHI r an In Plan Prvider. Refuse a treatment, drug, r ther prcedure recmmended by their dctr r ther health care prviders as the law allws. Prviders shuld tell Members abut any ptential medical effects f refusing treatment. Select an In Plan Primary Care Prvider (PCP) wh is accepting new patients. Fr a list f PCPs, Members can search the Minuteman Health Prvider Directry, visit the Prvider & Pharmacy search tl at r call the MHI Member Services team. Change their PCP. Members may chse any In Plan PCP, except thse wh have ntified MHI that they n lnger accept new patients. Have access, during MHI S business hurs, t the Member Services team wh can answer Members questins and help reslve prblems. Expect that their medical recrds and infrmatin n their relatinship with their dctr will remain cnfidential, in accrdance with state and federal law and MHI plicies. Make recmmendatins regarding MHI S member rights and respnsibilities plicies. Because MHI is member gverned, Members have a number f additinal Member rights. They may: Elect Members t the MHI Bard f Directrs (if they are age 18 r lder). Participate in the annual Members meeting. Have an pprtunity t be nminated as a candidate t be elected t the MHI Bard f Directrs. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 12 f 69

13 Member Respnsibilities As Members f MHI, Members have certain respnsibilities. These are t: Present their ID card at the time f receiving health care services. Prvide, as much as pssible, the infrmatin their prviders need t care fr them. This includes infrmatin n their present and past medical cnditins, as they understand them, befre and during any curse f treatment. Fllw the treatment plans and instructins fr care that they have agreed n with their prvider. Read MHI materials t becme familiar with their benefits and services. If Members have any questins, please call the Member Services team. Fllw all MHI plicies and prcedures. Treat prviders and MHI staff with the respect and curtesy that they wuld expect fr themselves. Arrive n time fr appintments r give prper ntice if they must cancel r will be late. Understand their health prblems, which is an imprtant factr in their treatment, and participate in develping mutually agreed upn treatment gals t the extent pssible. If a Member des nt understand their illness r treatment, they are respnsible fr talking it ver with their dctr. Participate in decisin making n their health care. Infrm MHI f any ther insurance cverage they may have. This helps us prcess claims and wrk with ther payers. Ntify us f status changes (such as a new address) that culd affect their eligibility fr cverage. Help MHI and In Plan Prviders get prir medical recrds as needed. Members agree that MHI may btain and use any f their medical recrds and ther infrmatin needed t administer the plan. Cnsider the ptential effects if they d nt fllw their prvider s advice. When a service recmmended by an In Plan physician is cvered, they may chse t decline it fr persnal reasns. Fr example, they may prefer t get care frm ut f plan prviders rather than In Plan Prviders. In these cases, MHI may nt cver substitute r alternate care that the Member prefers. Medical Recrds and Dcument Retentin Minuteman Health and its designated agents shall have the right t inspect and audit transcripts f any prvider s bks, recrds and dcuments necessary fr crrect cding initiatives and fraud, waste and abuse activities. Prviders are required t maintain the cnfidentiality f member recrds and infrmatin. Prviders are required t maintain these dcuments fr the Minuteman Perfrmance Perid which is Minuteman s CMS lan repayment perid plus 10 years. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 13 f 69

14 MINUTEMAN PRODUCTS AND BENEFITS Minuteman prvides insurance benefits t individuals and families as well as emplyer grups. We als prvide administrative services t health benefit plans spnsred and funded by emplyers themselves. We refer t these as self funded plans. An easy way t identify a self funded Member is by the grup number which can be fund n the Minuteman ID card. Self funded grup numbers always start with an SZ. It is imprtant t knw that ur insured plans cver New Hampshire mandated benefits; hwever, selffunded plans may cver NH mandates at the Emplyer s discretin. Als, Minuteman s insured plans include many standard benefits. These benefits are nt always standard amng ur self funded grups. If yu have any self funded eligibility r benefit questins please see r call Minuteman ffers several types f prducts t bth insured and self insured grups. Belw is a brief descriptin f ur prducts and selected benefits. Additinal plan and benefit details are available thrugh r by calling Under ur New Hampshire plans, In Plan Prviders include cntracted Minuteman Health prviders in bth ur New Hampshire netwrk and ur Massachusetts netwrk. Minuteman als cntracts with the natinal First Health netwrk t supprt ur POS prducts, with DentaQuest fr pediatric dental benefits available under certain plans, and with OptumRx (frmerly knwn as Catamaran) fr pharmacy benefits. Links t the First Health nline prvider search and a list f In Plan Dentists are available n MHI s website here: pharmacy search HMO Plans In New Hampshire, Minuteman sells HMO plans bth n and ff the Federal Exchange t individuals, families and small grups. We als sell plans t large grups. HMO member cst sharing may include cpayments, deductibles and cinsurance. There may als be limits n the number f cvered visits r services in a given calendar r plicy year fr certain categries f benefits. Additinal benefit details are available thrugh r by calling Prvider Services at (Select Optin 4). Primary Care Prvider Our HMO plans require that each Member select a primary care prvider (PCP). PCPs will either prvide medically necessary care r direct the Member t a Minuteman specialty prvider. Referrals t In Plan Prviders are nt required. Hwever, any directin t a nn participating prvider requires prir apprval by Minuteman if it is t be treated as a Cvered Service; therwise the claim may be denied. Only physicians, physician assistants and registered nurse practitiners in primary Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 14 f 69

15 care specialties (internal medicine, pediatrics and family practice) can be assigned as PCPs. Specialty Care Minuteman HMO Members may see participating specialists withut being referred by their PCP. Specialists can als refer Members t ther in netwrk specialists withut a frmal referral. Hwever, any referral t a nn participating prvider requires prir apprval by Minuteman, therwise the claim may be denied. Prir Authrizatins are required fr sme services. Failure t btain a required authrizatin may result in a denial f cverage and nn payment. (See Utilizatin Management starting n Page 32.) Pint f Service (POS)Plans Minuteman ffers several types f POS plans t grups. Members may visit In Plan Prviders wh have cntracted with Minuteman either directly r indirectly via the First Health natinal prvider netwrk (except fr emergency care, and urgent care btained utside the Minuteman service area). Cstsharing including cpayments, deductibles and cinsurance, will vary depending n whether the Member visits a MHI cntracted prvider ( Preferred ) r a First Health prvider ( Nn Preferred ). Services prvided by Out f Plan prviders, wh d nt cntract with either the Minuteman Health Netwrk f First Health, are nt cvered. Many f ur POS plans include pediatric dental essential health benefits thrugh ur relatinship with DentaQuest. Additinal benefit details are available thrugh r by calling Prvider Services at (Select Optin 4). Here is an verview f hw ur POS plans wrk: Prviders Medical Benefits & Cst Share Preferred Minuteman Health Netwrk Members incur the lwest ut f pcket cst MyDc POS Plan Overview In Plan Nn Preferred First Health natinal netwrk that includes hspitals, ancillary facilities and health care prfessinals Members have higher ut f pcket csts, but prviders must accept Minuteman s negtiated fees and cannt balance bill Out f Plan Any prvider wh des nt participate in the Preferred Minuteman netwrk r the Nn Preferred First Health natinal netwrk Nt cvered Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 15 f 69

16 PCP Member must select a PCP Members Nt required Nt applicable Referrals Nt required Nt required Nt applicable Pharmacy Benefits In Netwrk Pharmacy* Nt cvered* *Benefit will be cvered nly if filled at an In Netwrk pharmacy. Primary Care Prvider The POS plans require that each Member select an In Plan Preferred primary care prvider (PCP) in rder t receive the highest level f benefits (In Plan Preferred level f benefits). POS members wh live utside the MHI New Hampshire Service area may select In Plan Nn Preferred prviders frm the First Health Netwrk t act as their PCPs. PCPs will either prvide medically necessary care r refer the Member t an In Plan specialty prvider. Only physicians, physician assistants and registered nurse practitiners in primary care specialties (internal medicine, pediatrics and family practice) can be assigned as PCPs. Specialty Care POS Members may be seen by In Plan Preferred prviders as well as In Plan Nn Preferred Prviders. N PCP referrals are required. POS Members d nt have cverage if they see prviders wh d nt participate in the Preferred Minuteman netwrk r the Nn Preferred natinal netwrk. POS Members benefits are greater with less ut f pcket expenses when using In Plan Preferred Prviders. Please assist Minuteman POS Members whenever pssible t use In Plan Preferred Prviders. Services frm In Plan Nn Preferred Prviders are generally subject t higher cpayments and cinsurance levels than thse assciated with In Plan Preferred Prviders. As with ur HMO plans, Prir Authrizatins are required fr sme services under ur POS plans. Failure t btain authrizatins may result in a denial r reductin f benefits. Preventive Care Minuteman cvers a wide range f preventive services fr children and adults with n member cstsharing when they are rendered by In Plan Prviders. These include but are nt limited t rutine annual exams, immunizatins, rutine mammgrams, rutine clnscpies, certain cntraceptives and tbacc cessatin prducts. A cmplete list f these services is available n ur website here: nd%20dcuments/members_shppers/service%20grid/member%20preventive%20service%20grid.pdf Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 16 f 69

17 Emergency and Urgent Care What is an Emergency Medical Cnditin? An Emergency Medical Cnditin means the sudden and, at the time, unexpected nset f a health cnditin that requires immediate medical attentin, where failure t prvide medical attentin wuld result in serius impairment t bdily functins, serius dysfunctin f a bdily rgan r part, r wuld place the persn's health in serius jepardy. NH RSA 420 J:3 XV. In the Minuteman Service Area The Member always has cverage fr care is that is cnsidered an emergency. Minuteman encurages the Member t call their PCP first if pssible. If a Member calls their PCP, the PCP may direct the Member t his/her ffice, an ER, r urgent care facility. Minuteman requires PCPs t prvide n call cverage 24 hurs a day, seven days a week. The PCP (r the cvering physician) shuld call the Member back as sn as pssible if the Member reaches an answering service. Please remember that urgent care received inside the MHI New Hampshire service area must be rendered by In Plan Prviders. Fllw up Care Unless therwise indicated in this Prvider Manual, all emergency fllw up care must be crdinated by the Member s PCP. All Minuteman Members, including POS Members, have been instructed t cntact their PCP within 48 hurs f receiving care fr the Emergency Medical Cnditin t crdinate all fllwup care. Out f the Minuteman Service Area The Member always has cverage fr care that is cnsidered an emergency, even when he/she is utside f the Minuteman New Hampshire service area. Fllw up care nce an HMO Member is medically stable and able t return t the service area must be prvided r crdinated by the PCP. Starting in 2016, Members will have cverage fr urgent care received utside f the Minuteman New Hampshire service area. Please nte: POS Members shuld be encuraged t fllw up with their PCP. Out f netwrk nn emergent services will result in higher Member cst share. Emergency Inpatient Admissins Emergency r urgent inpatient admissins must be reprted t Minuteman within ne business day by the hspital r the admitting physician. Please call Health Services at (Select Optin 4, then Optin 4). If a Minuteman HMO Member is admitted t an ut f area hspital as a result f an emergency, Minuteman will cver the cst f services in that hspital nly until the Member s medical cnditin allws fr return t the service area and the care f the PCP. Please nte: this des nt apply t POS Members. If the Member is admitted t a hspital n an inpatient basis as the result f a medical Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 17 f 69

18 Emergency, the ER cpayment/cinsurance will be waived. Hspital deductibles and cst sharing will apply. The Member must pay a cpayment/cinsurance fr each ER visit if the visit des nt result in an admissin. Obstetrical and Gyneclgical Services Minuteman Members d nt need a referral r Prir Authrizatin t seek bstetric r gyneclgical services frm an In Plan Prvider wh specializes in bstetrics r gyneclgical care. This includes an In Plan gyneclgist, bstetrician, prfessinal nurse midwife r family practitiner. All In Plan Prviders are required t fllw Minuteman s plicies and prcedures fr Prir Authrizatins, as apprpriate, fr the services he r she prvides. Each female Minuteman Member is cvered fr ne rutine gyneclgical exam each calendar year. N referral is required. The annual gyneclgical exam may include a PAP smear and pelvic exam. The exam may be perfrmed by the Member s PCP r any In Plan participating gyneclgist. Family Planning Services Minuteman cvers Family Planning Services. This includes pregnancy testing and genetic cunseling. What is Cvered: Outpatient cntraceptive services. This includes cnsultatins, exams, and medical services that are prvided n an utpatient basis. Cntraceptive methds apprved by the Fd and Drug Administratin (FDA) and prescribed fr a wman by her health care prvider and subject t reasnable medical management. Nnprescriptin birth cntrl preparatins including but nt limited t cndms, birth cntrl fams and jellies, when prescribed by Prvider. Cunseling and diagnstic services fr genetic prblems and birth defects Family planning infrmatin and cnsultatin Pregnancy testing Sterilizatins Vasectmies Vluntary terminatin f pregnancy when allwed by New Hampshire law Types f Things that are Nt Cvered: All infertility services, including infertility testing, treatment and prcedures Reversal f vluntary sterilizatin Services related t achieving pregnancy thrugh a surrgate (gestatinal carrier) Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 18 f 69

19 Nnprescriptin birth cntrl preparatins including but nt limited t cndms, birth cntrl fams, jellies, and spnges, withut a prescriptin frm Prvider. Maternity Care Only an In Plan Prvider can prvide prenatal care. Als, an In Plan Prvider must arrange all inpatient care. What is Cvered: Prenatal visits and screening and pstpartum care. This includes cnsultatin fr breast feeding supprt, equipment and cunseling, screening fr pst partum depressin and parent educatin. There is n cst sharing fr rutine prenatal visits and screening and pstpartum care. Diagnstic tests Prenatal hmemaker services fr a wman wh (1) is cnfined t bed rest r (2) whse nrmal functins f daily life are restricted. Services must be medically necessary, as determined by an In Plan Prvider, wh shall cnsult with Minuteman s case manager, when applicable. Child Delivery, including a minimum f 48 hurs f inpatient care fllwing a vaginal delivery and a minimum f 96 hurs f inpatient care fllwing a caesarean sectin. Any decisin t shrten the inpatient stay fr the mther and her newbrn child will be made by the attending physician and the mther. Rutine nursery charges. These include services cmmnly given t healthy newbrns. T have Minuteman cver the child f the Subscriber r the Subscriber s spuse after birth, yu must enrll the child as a Member within 31 days f birth. Cverage will nt be prvided fr a newly brn child f a Dependent beynd 31 days. Newbrn hearing screening Pstpartum hmemaker services, when medically necessary, as determined by In Plan Prvider, wh shall cnsult with Minuteman s case manager, when applicable. What is Nt Cvered: Rutine maternity (prenatal and pstpartum) care when yu are traveling utside f the Minuteman Service Area. Delivery ut f the Minuteman Service Area after the 37th week f pregnancy. Minuteman als will nt cver delivery ut f the Minuteman Service Area if the Member has been tld that she is at risk fr early delivery. If the Member is pregnant, she may receive all f her pregnancy care and delivery, and ne rutine pstnatal ffice visit frm a participating bstetrician. The bstetrician must submit either the American Cllege f Obstetricians and Gyneclgists (ACOG) Antepartum Recrd Frm r the Obstetrical Pre Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 19 f 69

20 Registratin Frm, fllwing the Member s first prenatal visit, t Health Services. The frm cntains a sectin fr Obstetrical High Risk/Pre term Labr Assessment which is cmpleted and submitted fllwing the first prenatal visit and again fllwing subsequent visit(s) if a risk factr is identified. Health Services will use the frm t evaluate the need fr Case Management services. Health Services will als cnfirm that the delivery will take place in a netwrk facility t minimize the Member s ut f pcket csts. The bstetrician is respnsible fr all bstetrical services and referrals related t the Member s pregnancy. The bstetrician may als prvide rutine medical services unrelated t the Member s pregnancy. Any elective surgical prcedures t be perfrmed during the hspital admissin and fllwing delivery (i.e., planned tubal ligatin) shuld als be cmmunicated t Minuteman by submitting the ACOG frm either at the initial r subsequent visits. These services d nt require submissin f a separate Standardized Prir Authrizatin Request Frm. Please fax the ACOG Antepartum Recrd r Pre Registratin frm t Minuteman Health Services at A cpy f the Clinical Guideline fr Uncmplicated Obstetric Care and frms may be btained by calling Minuteman Health Services at (Select Optin 4, then Optin 4) r by referring t the website at The bstetrician shuld als remind the pregnant Member t select a participating pediatrician t prvide services t the newbrn. Mammgrams Rutine screening mammgrams are als cvered as preventive services. A baseline mammgram may be btained between the ages 35 and 39, then ne mammgram is cvered per calendar year fr Members ages 40 and ver. Nn preventive mammgrams are cvered as medically necessary and require member cst sharing. Rutine Visin Exam Each Minuteman adult Member in an insured plan is currently cvered fr ne visin exam per 24 mnths each calendar year. Starting in 2016, adults will be cvered fr ne rutine eye exam every calendar year. Each child Member (under age 19) in a Minuteman New Hampshire plan is cvered fr ne rutine eye exam, a pair f frames frm a designated MHI cllectin, eyeglass lenses (standard plastic up t 55 mm single visin, bifcal, trifcal, prgressive), elective cntacts in lieu f glasses and nn elective cntacts fr certain cnditins in lieu f glasses, per calendar year. N referral is required. The exam may be perfrmed by any participating ptmetrist r phthalmlgist. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 20 f 69

21 Chirpractic Benefit When chirpractic benefits are cvered, they are limited t 12 visits in a calendar year. Minuteman Members may self refer as medically necessary fr up t all 12 visits t a chirpractr wh is an In Netwrk Prvider. Please nte: Minuteman des nt cver X rays when dne in a chirpractic ffice. Chirpractrs are directed t refer Members t their PCPs fr crdinatin f these imaging services. Outpatient Surgery Sme Minuteman HMO and POS plans include lwer cst sharing fr Members if they visit designated Select Minuteman cntracted prviders fr Outpatient Surgery. See ur nline prvider directry t identify Select prviders in the MHI New Hampshire prvider netwrk. Durable Medical Equipment (DME) At Minuteman, the term DME is used t dente anything billed with an A, E, L, r K HCPCS cde, with a few exceptins (e.g. certain drugs and pharmaceuticals). This includes standard durable medical equipment, high tech r ther specialized DME, medical and surgical supplies, stmy supplies, xygen and respiratry equipment and supplies, and rthtics and prsthetics. Mst DME is dispensed t Minuteman Members by cntracted DME and rthtics & prsthetics vendrs. Hwever, certain DME prducts may be dispensed t Members by physicians at the time f the visit, by hspitals and by ther cntracted Minuteman vendrs r manufacturers wh dispense specialized prducts. Standard items will be dispensed unless the physician s rder specifies a nn standard item. DME Dispensed by Physicians In Plan Physicians may prvide Members with therapeutic and medically necessary DME during an ffice visit, especially in instances where the dispensing f such DME items is essential t prviding timely and effective care t the Member versus referring the Member t a DME vendr (e.g. splint). Minuteman will reimburse Minuteman In Plan Physicians fr such DME at its standard Physician Office Allwable DME Fee Schedule. (Fr POS members, Nn Preferred First Health DME prviders will be reimbursed per the terms f their First Health Cntracts.) In instances where, in the physician s pinin, it is nt medically necessary t dispense the DME frm the physician s ffice, the physician s ffice shuld either cntact an In Plan DME vendr t have the item(s) delivered t the Member s hme r give the Member a written rder fr the DME. The Member can either visit an In Plan DME vendr r call t arrange fr the items t be delivered t their hme. Certain equipment and supplies, fr example, gauze, is included in the physician s ffice visit fee and will nt be paid separately, nr is it cvered when prvided by the DME vendr. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 21 f 69

22 Hearing Aids and Services: Minuteman cvers hearing aids t the extent required by New Hampshire law. A hearing aid is defined as any instrument r device designed, intended r ffered fr the purpse f imprving a persn s hearing. Minuteman currently cvers ne hearing aid every sixty (60) mnths pursuant t New Hampshire law. Starting in 2016, Minuteman will cver hearing aids (including parts, attachments r accessries, including ear mldings) when medically necessary (i.e., each time a hearing aid prescriptin changes). N back up hearing aids that serve a duplicate purpse are cvered. Services necessary t assess, select, fit r service the hearing aid must be prvided by an In Plan Prvider wh is a licensed audilgist, hearing instrument specialist r licensed physician. Labratry Services All labratry testing must be medically necessary and related t an active treatment plan. The rdering physician must prvide the Member with a written rder if the test is nt prvided n site. The rdering physician must always direct the Member r Member s specimen t a Minuteman participating labratry prvider t ensure cverage. Members shuld als verify that the labratry is a participating prvider. Bld specimens may be drawn in the physician s ffice. If testing is nt perfrmed in the ffice, nly phlebtmy services may be billed. Minuteman des nt allw pass thrugh billing n labratry exams. Minuteman Physician Office Allwable Lab Tests Subject t their prvider cntracts, Minuteman participating physicians may perfrm labratry tests in their ffice fr Minuteman Members and may bill and be reimbursed by Minuteman n a fee fr service basis. The prvider ffice labratry (when applicable) must meet all lcal, state, and federal requirements relating t physician ffice labratry standards and licensing. Select Lab Prviders Sme Minuteman HMO and POS plans include lwer cst sharing fr Members if they visit Select labratry prviders. See ur nline prvider directry t identify Select lab prviders in the MHI New Hampshire prvider netwrk. Behaviral Health Services Mental Health Services MHI will nly cver mental health services when they are Medically Necessary. MHI cvers all mental disrders that are described in the mst recent editin f the Diagnstic and Statistical Manual f the American Psychiatric Assciatin (DSM). Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 22 f 69

23 Substance Abuse Services MHI cvers the diagnsis and treatment f substance abuse. The treatment can be inpatient and utpatient treatment. Outpatient treatment must be prvided by a physician r psychtherapist wh spends a large part f his r her time treating substance abuse. MHI als cvers Medically Necessary inpatient detxificatin. All treatment must be Medically Necessary. What is Nt Cvered: Educatinal services r testing, except services cvered under the benefit fr Early Interventin services Psychanalysis Services fr prblems f schl perfrmance Faith based cunseling Scial wrk fr nn mental health care Christian Science practitiner and sanitarium stays Residential/custdial services (including residential treatment prgrams, sber huses and halfway huses) Testing and treatment services at these facilities nt cvered Miscellaneus Services including Pain Management, Bifeedback and Neurpsychlgical Testing Minuteman insured plans cver Telemedicine furnished r apprved by the PCP fr Medically Necessary services that wuld be Cvered Services if prvided during an in persn cnsultatin. Bth the Netwrk prvider and Member must be present and participating. Minuteman insured plans cver clinical trials if federally funded as part f an apprved clinical trial (phases I IV). Experimental devices and drugs that may be part f these trials are nt cvered by Minuteman. Varius types f prviders including hspitals, mental health clinicians and anesthesilgists may prvide pain management services. Cpayments are applicable fr pain management services, including an utpatient hspital cpayment, if services are perfrmed in the hspital. Bifeedback is excluded frm cverage fr medical cnditins ther than urinary incntinence. Bifeedback fr urinary incntinence requires prir apprval. Bifeedback fr mental health is treated like therapy and prir authrizatin frm Minuteman Health Services is required. Bifeedback t treat ADHD and ADD is nt a cvered benefit. Neurbifeedback is nt a cvered benefit. Neurbifeedback is a nn invasive technique that is used t teach patients hw t stimulate and suppress brainwaves f specific frequencies. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 23 f 69

24 Neurpsychlgical testing is cvered. The physician ffice visit cpayment applies. Prir apprval frm Health Services is required fr Members. Neurpsychlgical testing is nt apprved as a first assessment apprach fr Attentin Deficit/Hyperactivity Disrder. Pediatric Dental Services Under sme f ur plans, we cver pediatric dental essential health benefits fr members under age 19 when prvided by an In Plan dentist wh participates in the cntracted DentaQuest dental netwrk. Cvered services under these plan types include the fllwing: Diagnstic & Preventive Services Tpical fluride treatment, nce every 6 mnths (member cst sharing des nt apply fr children up t age 5) Peridic ral exams, 2 per year Rutine cleanings, nce every 6 mnths Bitewing x rays, 1 set every 6 mnths Panramic x rays, 1 image every 60 mnths Minr Restrative Services Fillings Pre fabricated stainless steel crwns, under age 15, 1 per tth every 60 mnths Pre fabricated prcelain crwns, primary, 1 per tth every 60 mnths Simple tth extractins Incisins and drainage f abscess Tissue cnditining Repair f crwns Palliative treatment f dental pain Adjustment f dentures Cmplex Restrative Services Crwns, 1 per tth every 60 mnths Rt canals Peridntic services (limits vary) Enddntic services (limits vary) Onlay, metallic, 1 every 60 mnths Inlay, metallic, 1 every 60 mnths Dentures, 1 every 50 mnths Implants, 1 every 60 mnths Orthdntic Services Only medically necessary rthdntic treatment is cvered. Members must have a severe and handicapping malcclusin. All rthdntic services (including interceptive rthdntic treatment) require prir authrizatin. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 24 f 69

25 Prvider questins abut Minuteman s dental cverage, prir authrizatin, claims etc. shuld be directed t DentaQuest at Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 25 f 69

26 PHARMACY SERVICES Nte: Pharmacy Prir Authrizatin Line (OptumRx): Minuteman plicies and benefits related t pharmacy are driven by Minuteman s pharmacy utilizatin and therapeutic interventin prgrams t help ensure that Members have access t quality care thrugh clinically sund and cst effective drug utilizatin. Our clinical pharmacists versee the pharmacy and therapeutics prgram and wrk with OptumRx (frmerly knwn as Catamaran), Minuteman s pharmacy benefits manager. Pharmacy and therapeutics management cnsists f a frmulary, generic drug substitutin, targeted benefit restrictins, drug utilizatin review, prir apprvals, step therapy, and a pharmacy netwrk. Belw are verviews f each prgram cmpnent. Mre detailed and current infrmatin can be fund at Prescriptin Benefit: Mst Minuteman Members are cvered fr prescriptin drugs btained at participating pharmacies. Drugs cvered by Minuteman s clsed New Hampshire frmulary are rganized int cst sharing tiers as fllws: Tier 1: Generics Tier 2: Preferred Brand name Tier 3: Nn Preferred Brand name Tier 4: Specialty Tier 5: ACA Preventive Drugs (n cst sharing) If Members have prescriptin drug cverage, this is nted at the bttm f the ID card (fr example, RX$10/20/35). The retail prescriptin drug benefit is nrmally limited up t a thirty (30) day supply. Please see the Medicatins at Retail sectin belw. A Member can receive a ninety (90) day supply f maintenance medicatins either at a retail lcatin r by mail rder depending n the Member s plan. Please see the Medicatins at Mail Order sectin belw. A Member wh has taken a frmulary drug fr ne year r mre can be prescribed a ninety (90) day supply, but any applicable prir authrizatin r UM prgrams wuld cntinue t apply. Cntrlled substances are nt available in a ninety (90) day supply. Minuteman In Plan Pharmacy Netwrk: Members can fill prescriptins at any f the mre than 50,000 In Plan Pharmacies that participate in ur natinal netwrk. Participating In Plan Pharmacies include mst majr pharmacy chains as well as retailers such as Cstc and Wal Mart. In Plan Pharmacies can be searched n the Minuteman website Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 26 f 69

27 at Over the Cunter Medicatins: Minuteman cvers a number f ver the cunter (OTC) medicatins with a prescriptin as required by the Affrdable Care Act withut a cpay. Please refer t ur frmulary listings at fr additinal detail. Cmpunded Medicatins: Cpayments fr cmpunds will vary based upn the ingredients. Hwever, nt all cmpunds are cvered and sme may be subject t prir authrizatin. Fr questins regarding cverage, please call Minuteman Member Services at (Select Optin 4, then Optin 4 again). Maintenance Medicatins at Retail: Minuteman s Access 90 prgram allws ur Members t receive up t a ninety (90) day supply f maintenance medicatins and any ther medicatins that are nt a cntrlled substance that have been taken at participating retail pharmacies. A cpayment will apply t each thirty (30) day supply. The Access 90 prgram des nt apply t prescriptins filled at Minuteman's specialty vendr r if prhibited by law. Fr a listing f Access 90 participating pharmacies call Minuteman Member Services at Maintenance Medicatins at Mail Order: Members with the mail rder benefit may btain up t a ninety (90) day supply f maintenance medicatins thrugh the mail. Please ensure that the Member has filled as least 2 refills at retail and has nt had an adverse reactin befre setting up mail rder. Please verify that the medicatin is a maintenance medicatin as defined by Minuteman by visiting Please cmplete and submit the mail rder prfile available at Fr faster service ur Members can rder refills nline at as indicated n the invice received frm the mail rder cmpany. This nly applies t prescriptins with refills and des nt apply t any initial rders. Specialty Medicatins: Members being treated with specialty medicatins are required t use cntracted specialty pharmacies t fill ral nclgy and self injectable medicatins with the exceptin f insulin prducts. Minuteman s specialty vendrs supply all frms f injectable medicatins fr Minuteman Members with a prescriptin benefit. Members withut the benefit are cvered nly fr medical injectables (i.e., administered by a medical prfessinal) and are nt cvered fr self injectables. Order frms fr specialty medicatins are Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 27 f 69

28 available n line at r can be faxed t yu by calling Minuteman Member Services at (Select Optin 4). Minuteman s specialty vendr will prvide injectable drugs t Minuteman Members in the fllwing settings: Private physician ffices Hspital clinics Members hmes This service is prvided t bth Members and prviders. Yu can call Member Services at t request drug rder frms. Minuteman New Hampshire Frmulary The Minuteman New Hampshire frmulary is a clsed five tier frmulary that is designed t meet Essential Health Benefit requirements. As part f the frmulary evaluatin prcess, Minuteman uses an algrithm based n safety, efficacy and cst. All frmulary recmmendatins are discussed at the Minuteman Quality and Utilizatin Management Cmmittee, which acts as ur Pharmacy and Therapeutics Cmmittee, prviding a frum fr clinician invlvement. The Pharmacy and Therapeutics Cmmittee reviews drug categries thrughut the year evaluating requests fr drug categry additins as the categry is reviewed. Recently apprved drugs that fill a treatment vid may be reviewed ut f cycle. In general, newly apprved drugs are nt added t Minuteman s frmulary right away. There is at least a six mnth waiting perid after the drug is apprved called the Clinical Review Perid (CRP). Minuteman des nt cver the newly apprved drugs during the Clinical Review Perid. Imprtant Criteria: Drugs reviewed fr additin must be FDA apprved. Drugs under cnsideratin will be cmpared t existing therapies and will be evaluated based n quality dimensins. If the drug under cnsideratin is nt similar t existing agents and is the nly drug in its class, the evaluatin will be made against existing therapies, including nn drug therapies. The frmulary is reviewed annually and as necessary thrughut the year. Prviders can receive a frmulary listing upn request r n the website. Drugs added r deleted frm the frmulary during the year are cmmunicated thrugh peridic mailings t prviders and Members, and are psted n Minuteman, thrugh OptumRx, maintains an expedited exceptins prcess, allwing Members t receive a decisin n whether Minuteman will cver a nn frmulary drug within 24 hurs. T request a frmulary exceptin, submit a request with a clinical ratinale in accrdance with the instructins n the OptumRx website. Minuteman allws ff label drug use. In certain circumstances ff label use may require a Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 28 f 69

29 prir authrizatin. The drug and the treatment methds must be recgnized either in medical literature r in standard reference cmpendia. Generic Drugs Minuteman supprts and encurages the use f FDA AB rated generic pharmaceuticals fr Minuteman membership. Apprved FDA AB rated generic drugs (Tier 1 cst sharing) cntain the same active ingredients as brand name drugs, are just as safe and effective and usually cst less. Pharmacists are permitted t substitute generic drugs unless the prescribing physician handwrites "medically necessary" n the prescriptin r, if rdering by telephne, specifies rally that the drug is medically necessary as written. Minuteman Members pay the lwest cpayment fr generic drugs. When yu prescribe a brand name medicatin and an apprved FDA AB rated generic is available yu will need t cmplete and submit a Prir Authrizatin Frm, available at T assist in expediting yur medicatin request make sure yu cmplete all questins n the frm. Prvide yur assessment f medical necessity fr the brand prduct nly. Include any dcumentatin such as ffice ntes, call lg(s), actin steps taken shuld the Member have experienced an adverse reactin, serius side effect, and/r lack f efficacy t the generic prduct. Minuteman encurages yu t g t the FDA website and cmplete a Medwatch Adverse Event Reprting Frm if the Member had a serius adverse event. Yur request will be reviewed and a determinatin will be based n the infrmatin yu prvide. Newly Apprved Drugs In general, new brand name drugs, r existing drugs with new treatment purpses, are nt added t Minuteman s Frmulary right away. There is a minimum six mnth waiting perid after they are apprved by the FDA called the Clinical Review Perid (CRP). This applies t all new drugs, including thse dispensed at a retail pharmacy, frm a specialty pharmacy, in the dctr s ffice r in an infusin suite. Minuteman des nt cver drugs during the CRP. Yu may ask us t make an exceptin. If we apprve cverage f the drug during the CRP, the cpay will be 50% f the cst f the drug. At the end f the CRP, Minuteman may decide nt t cver the drug and add it t the exclusin list. If this happens, Minuteman will nt cver the drug after the CRP. If Minuteman des decide t cver the drug, the cpay will be the amunt fr the tier t which the drug is assigned. After review, the drugs will be cvered under tiers 2, 3 r 4 depending n their placement in the Minuteman frmulary. This des nt apply t newly apprved generic drugs. Generic drugs are cvered under the lwest cpayment level (Tier 1). Excluded Drugs Fr the mst current list f excluded drugs, please call Member Services at Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 29 f 69

30 Review Prcess If a physician requests an FDA apprved medicatin fr a nn FDA apprved disease state/cnditin, the criteria fr its use will be based upn at least 3 peer reviewed jurnal articles, natinal guidelines and current standard f care. If the use f the medicatin des nt fall int any f these categries, Minuteman s Pharmacy Services Department will generally deny the request. Yu can btain a cpy f the Clinical Review Perid Benefit Exceptin frm at by searching the drug in questin. The frm will be available in the search results. Medical /Pharmacy Benefit Drugs Requiring Prir Authrizatin Minuteman cntinually mnitrs and evaluates new drug infrmatin, drug utilizatin and frmulary cmpliance t meet ur gal f prviding high quality pharmaceutical care. As part f this prcess, Minuteman limits quantities and use f certain drugs and requires prir authrizatin fr thers. In rder t btain a supply f medicatin request frms r a list f any medical r pharmacy drugs that require apprval, visit r call Member Services at (Select Optin 4). Cmplete the apprpriate drug prir authrizatin frm and fax it t the number n the frm. Our PBM, OptumRx, ffers ur prviders the ptin t call in fr prir authrizatin by calling The PBM will cntact the prvider if necessary and will ntify yu f all decisins. They als prvide an pprtunity fr case discussin and recnsideratin f adverse determinatins. Drugs with Quantity Limits Fr the mst current list f medicatins with quantity limits r quantity based cpayments, please call Member Services at (Select Optin 4), r use the nline drug search at Cmpleted frms shuld be faxed t the number n the frm. Only FDA maintenance indicatr drugs are allwed thrugh mail rder. Step Therapy Prgram Step Therapy is an apprach t medicatin management. Step Therapy is a prgram designed fr certain cnditins diabetes, high bld pressure and high chlesterl. The Minuteman Step Therapy prgram is all abut value. Mst simply, that means getting a tried and true medicatin that is prven safe and effective fr the cnditin and getting it at the lwest pssible cst. This prgram is designed t have prescriptin drugs be mre affrdable. We will wrk with yu t be certain that ur Members are getting the apprpriate drug fr their cnditin. The use f samples des nt satisfy the requirements f dcumented usage f a first r secnd line drug f medical necessity fr a Step Therapy drug. If it is medically necessary fr yur patient t use a Step Therapy drug befre trying a first and/r secnd line Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 30 f 69

31 drug, please cntact Minuteman t request a pharmacy review. If yu have any questins abut the prgram please cntact Member Services at (Select Optin 4), r use the nline drug search at Minuteman will nt require failure n the same medicatin n mre than ne ccasin fr patients cntinuusly enrlled in the plan. Nte: Sme f these Step Therapies have 3 steps. Members must try the first line drug befre Minuteman will cver the secnd line drug. Members must try the secnd line drug befre Minuteman will cver the Step Therapy drug. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 31 f 69

32 UTILIZATION MANAGEMENT Prir Authrizatin Prcess Minuteman Health Services Cntact Infrmatin: Phne: (Optin 4, then Optin 3) Health Services FAX: Prvider Prtal: Fr Diagnstic Imaging: Cntact evicre/medslutins at Fr Rx Prir Authrizatin: Cntact OptumRx (frmerly knwn as Catamaran) at IMPORTANT INFORMATION: Prir authrizatin is required fr the elective admissins/services listed belw whether they are administered in plan r ut f plan. The respnsibility f btaining prir authrizatins frm Minuteman Health is the sle respnsibility f the prvider. This respnsibility includes, but is nt limited t, drafting and submitting prir authrizatin frms. If a prvider des nt btain prir authrizatin in accrdance with Minuteman Health s plicies and prcedures, Minuteman Health will nt pay the prvider fr these claims. Prviders in Minuteman Health s netwrk understand and agree that members are nt financially liable fr services btained withut the prvider btaining prir authrizatin and additinally agree that they will nt balance bill members fr services in accrdance with New Hampshire law. All ut f plan elective services require a prir authrizatin request frm the PCP must be submitted t Minuteman fr review if the service is t be treated as a Cvered Service r, fr Members enrlled in a POS plan, t be cvered at an in Netwrk level f cverage. Behaviral health/substance abuse admissins d nt require prir authrizatin, hwever, the facility must cntact the Minuteman Health Services department within ne business day t initiate cntinued stay review. Inpatient stays and nging services are reviewed cncurrently. Submit request fr prir authrizatin t Minuteman Health Services, by phne r fax prir t the scheduled admissin/service. Requests may be submitted using the Standardized Prir Authrizatin Request Frm available at Specific frms can als be fund fr requests fr Behaviral Health and Enteral Nutritin can be fund n ur website. Prvide cmplete, pertinent clinical infrmatin in rder t avid a delay in making a determinatin. When changes are made t this list, prviders will be ntified in writing 60 days prir t the change ging int effect. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 32 f 69

33 Prir Authrizatin must be btained even when anther insurer may be primary. Minuteman Health Prir Authrizatin List Sme treatments and services require Prir Authrizatin. These services and treatments are cvered nly if Minuteman Health, Inc. (MHI) authrized them in advance. If any nn authrized and/r nn cvered service r treatment, such as a csmetic prcedure, is perfrmed at the same time as the authrized services, MHI may deny the nn authrized and/r nn cvered service r treatment. T get Prir Authrizatin, the treating dctr must cntact MHI. The dctr can either send us a Prir Authrizatin Request Frm r cntact MHI by phne. Admissins t: Acute care facilities Skilled nursing facilities Acute rehabilitatin facilities Hspice Transplants Human rgan Bne marrw Autlgus chndrcyte Diagnstic Imaging* (Cntact evicre at ) CT scans MRA s MRI s PET s Nuclear cardiac imaging perfrmed in a physician s ffice r utpatient facility *Imaging prcedures perfrmed while a patient is in the emergency rm, bservatin, r is an inpatient, d nt require prir authrizatin. Surgical Prcedures Abdminal panniculectmy Bariatric surgery and surgical management f mrbid besity Blepharplasty Cchlear implants Endthelial keratplasty Gender reassignment surgery (MA) Implantable Miniature Ocular Telescpe (IMT) Prsthesis Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 33 f 69

34 Infuse bne graft Mammplasty, reductin Mbi C artificial cervical disc Obstructive sleep apnea crrective surgeries, invlving palate, uvula, r related structures Orthgnathic surgery Radifrequency ablatin fr chrnic spinal pain Remval f impacted teeth when perfrmed in an utpatient facility (fr bth the facility and anesthesia) Rhinplasty Sacriliac jint fusin Stimulatrs Bne grwth Gastric electrical Sacral nerve Spinal crd Stretta prcedure Ttal ankle replacement (TAR) Ttal hip resurfacing Uvulpalatplasty, laser assisted Therapies Speech Hme Health Care Skilled nursing Infusin therapy Perinatal mnitring PT,OT, Speech Therapy Hspice DME, Orthtics & Prsthetics** Cardiac defibrillatr, wearable BIPAP, Pressure Supprt Ventilatrs High cst equipment, including certain repairs and maintenance Air fluidized beds Bne grwth stimulatrs Cchlear implants Cntinuus glucse mnitring systems Vice synthesizers fr mnitrs used by legally blind Custmized items and supplies (Sme)Diabetic equipment and supplies, Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 34 f 69

35 High frequency chest wall cmpressin devices Hme use f xygen Inter pulmnary percussive ventilatin systems Specialized beds/mattresses fr wund care Speech generating devices Wheelchairs, pwer and ther certain wheelchairs Wund care supplies Wund vac systems Insulin pumps Therapeutic shes and rthtics Prsthetic limbs Facial prstheses (including artificial eyes) Infusin & Nutritinal Supprt IVIG Frmula and enteral nutritin Lyme disease treatment Injectable drugs Fr a list f injectable drugs cvered under the medical benefit and prir authrizatin requirements, check the MHI Drug Frmulary at r call MHI Health Services at (Select Optin 2, then Optin 4). OB/GYN Infertility Treatment (MA) AI, IUI, IVF EP, GIFT, ZIFT, FET, ICSI, assisted hatching, crypreservatin f eggs Pre implantatin genetic diagnsis Pregnancy After first prenatal visit, fax pre registratin frm frm t MHI Health Services at , which will serve as prir authrizatin fr admissin n EDC ACOG Antepartum Recrd Frm may be used Re submit updated pre registratin frm when a risk factr is identified at a subsequent visit Behaviral Health/Substance Abuse (* MA certain services in Massachusetts cannt be subject t prir authrizatin but can require a ntificatin requirement and subsequent cncurrent review) Acute residential treatment (ART)/Cmmunity Based Acute Treatment (CBAT)* Applied Behaviral Health Analysis (In NH, prir authrizatin is nt required. Tw (2) visits fr diagnsis fllwed by up t three (3) treatment visits in each cntract year are cvered withut review. Subsequent visits with the cntract year may be subject t utilizatin review. The treatment plan must be submitted.) Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 35 f 69

36 Crisis Stabilizatin Unit (CSU)/Cmmunity Crisis Stabilizatin (CCS) Day treatment * Partial hspitalizatin prgram (PHP) * Family stabilizatin therapy (FST) * Intensive utpatient therapy (IOP) * Repetitive transcranial magnetic stimulatin (rtms) Neurpsychlgical testing Clinical Stabilizatin Services (CSS) /Cmmunity Stabilizatin Services (CSS) and Acute Treatment Services (ATS) (Cvered in MA nly mandated cverage. In plan prvider ntificatin required within frty eight (48) hurs and prir authrizatin required n day 15. Out f plan prviders must have prir authrizatin.) Other Ambulance, nn emergency, including air ambulance Bifeedback Cardiac mnitring Chair van services Cleft lip and palate treatment Clinical trials Dental prcedures perfrmed in a hspital setting Dermal injectins fr the treatment f facial lipdystrphy syndrme (LDS) Fecal micrbita transplant Genetic testing Hearing aids fr members age 21 and yunger Hyperbaric xygen treatment, utpatient (HBO) Insulin pumps Lyme disease treatment IV antibitics Mandibular advancement device fr treatment f sleep apnea Oncgene typing assciated with treatment f breast cancer Prtn beam therapy Phtchemtherapy (PUVA) and Phttherapy Scleral lens Sleep Studies **Durable Medical Equipment (DME) At MHI the term DME is used t dente anything billed with an A, E, L, r K HCPCS cde, with a few exceptins f certain drugs and pharmaceuticals). This includes standard durable medical equipment, hightech r ther specialized DME, medical and surgical supplies, stmy supplies, xygen and respiratry equipment and supplies, and rthtics and prsthetics. MHI des require DME vendrs t receive a prescriptin frm a physician r rdering practitiner prir t dispensing an item t ensure that it is medically necessary. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 36 f 69

37 The vendr is nt required t submit the prescriptin t be reimbursed, hwever, MHI may request t see the physician s prescriptin rder. Very few DME items require prir apprval by Health Services prir t dispensing. Fr infrmatin n member respnsibility as well as requirements fr prir authrizatin please call MHI Member Services at (Select Optin 4). New Technlgy and Prcedures Prviders wh intend t implement the use f a new service, technlgy r prcedure, r implement a new use fr an existing technlgy r prcedure, must prvide written ntificatin t Minuteman Health nt less than (60) days prir t such implementatin fr apprval. Minuteman Health will determine cverage and reimbursement guidelines, including but nt limited t payment rates and authrizatin requirements fr such new technlgy r prcedure fr the intended site f service. If a prvider des nt btain such apprval, Minuteman Health will nt pay claims fr these services. Additinally, members will have n financial liability fr new services prvided withut Minuteman Health s expressed apprval. These requests shuld be faxed t Minuteman Health Services at UM Decisin Prcess All UM decisins are made in accrdance with the terms f the Member s Evidence f Cverage (EOC) dcument in a fair and cnsistent manner. When making a determinatin f cverage based n medical necessity r apprpriateness, Minuteman will render the decisin in accrdance with defined UM criteria and will evaluate all relevant clinical infrmatin, including the individual Member s particular health care needs and the capability f the lcal delivery system. Written criteria gvern all decisin making. The Minuteman UM Decisins plicy sets frth the timeframes fr UM decisin making and the prcess fr ntificatin f UM decisins. It is Minuteman s plicy t meet bth state and federal regulatry requirements as well as t meet r exceed NCQA standards and requirements. At a minimum, this plicy is updated n a biannual basis. Minuteman will ntify prviders in writing f changes r mdificatins t the UM prgram that have a substantial impact n the rights r respnsibilities f the prviders and the effective date f such mdificatins. If prviders wuld like a cpy f Minuteman s mst recent UM Decisins plicy r UM Criteria, prviders may request a cpy by calling Health Services at (Optin 4, then Optin 4). Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 37 f 69

38 Physician Reviewers The Chief Medical Officer and/r apprpriate specialists and clinical practitiners are cnsulted fr cases that d nt meet medical necessity criteria. Prgram staff may nt make denial f service determinatins fr medical necessity. The Chief Medical Officer r his r her designee is the final decisin maker fr any denial based n medical necessity. Utilizatin Management decisin making is based nly n the apprpriateness f care and service and existence f cverage. MHI des nt specifically reward practitiners r ther individuals fr issuing denials f cverage. Financial incentives fr UM decisin makers d nt encurage decisins that result in underutilizatin. Criteria and Medical Necessity Cnsistent with generally accepted principles f prfessinal medical practice and in cnsultatin with the Member, the physician treating a Member makes all clinical decisins regarding medical treatment t be prvided t the Member, including the prvisin f durable medical equipment and hspital lengths f stay. Nthing in this sectin shall be cnstrued as altering, affecting r mdifying either the bligatins f any third party r the terms and cnditins f any agreement r cntract between either the treating physician r the Member and any third party. In reviewing requests fr prir apprval, Minuteman may cnsider whether the service: Is a cvered benefit r service Is medically necessary Is being prvided in the apprpriate setting Fllws generally accepted medical practice Is available within the Minuteman netwrk Meets Minuteman s clinical criteria fr cverage Minuteman utilizes cmmercially purchased criteria sets, (Interqual), t assist with making level f care determinatins. Minuteman s cmmercially purchased criteria sets are licensed criteria sets, which are the PROPRIETARY and CONFIDENTIAL prperty f the licensing cmpany. Minuteman has a cntractual bligatin t prtect the cnfidentiality f these licensed criteria. Minuteman makes available t the treating prvider and the Member the specific prtin f the criteria used where required by law r by applicable accreditatin requirements. Minuteman als utilizes internally develped criteria that are used as a guideline when applying the standard f medical necessity fr select prcedures, treatments, and services. Prviders wh wuld like a cpy f the internally develped clinical criteria that are used t make UM determinatins shuld Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 38 f 69

39 cntact Health Services at (Select Optin 4, then Optin 3) r can access the criteria at The internally develped medical necessity guidelines utilized by Minuteman in making cverage determinatins are: Develped with input frm practicing physicians. Evidence based and develped in accrdance with the standards adpted by natinal accreditatin rganizatins. Updated at least annually as new treatments, applicatins and technlgies are adpted as generally accepted prfessinal medical practice. In applying such guidelines, Minuteman cnsiders the individual health care needs f the Member. In additin, Minuteman will ntify Members and prviders sixty (60) days prir t the effective date f any material changes t Minuteman s criteria. With respect t a Member enrlled in a health benefit plan under which Minuteman nly prvides administrative services (i.e., fr Members enrlled in a Self Funded plan), the payer may reserve the right t decide certain appeals f benefit denials. If s, Minuteman s rle with respect t payment is limited t the benefit cverage recmmendatin f the payer. Minuteman defines medically necessary in accrdance with New Hampshire law as fllws: health care services r prducts prvided t a Member fr the purpse f preventing, stabilizing, diagnsing r treating an illness, injury r disease r the symptms f an illness, injury r disease in a manner that is: Cnsistent with generally accepted standards f medical practice; Clinically apprpriate in terms f type, frequency, extent, site and duratin; Demnstrated thrugh scientific evidence t be effective in imprving health utcmes; Representative f "best practices" in the medical prfessin; and Nt primarily fr the cnvenience f the Member r physician r ther health care prvider. Of nte, medical care shuld nt be perfrmed in a way that financially benefits the prvider at the expense f Minuteman Members. Inquiring Abut the Status f a UM Decisin Practitiners have direct access t UM staff regarding specific cases and discussin f UM decisins. In general, if a prvider requests a service that requires Minuteman s prir apprval and wuld like t knw its status r utcme, the prvider shuld cntact Health Services at (Optin 4, then Optin 4), between 8:00 a.m. and 6:00 p.m., Mnday thrugh Friday. Practitiners may als call Minuteman UM Departments at delegated entities directly as fllws: High Cst Radilgy and Imaging Call evicre/medslutins at Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 39 f 69

40 Pharmacy Issues Call OptumRx at Submitting Additinal Infrmatin in the Case f an Adverse Determinatin When a prvider has received an adverse determinatin and has additinal infrmatin that may influence the decisin, the prvider r his/her ffice staff shuld cntact the Minuteman Nurse Case Manager s that the request is reviewed again based n this new infrmatin. The Nurse Case Manager will review the new infrmatin and refer t a physician if unable t reverse the adverse determinatin. Recnsideratin f an Adverse Determinatin If an adverse decisin is based n medical necessity and apprpriateness, the prvider may request a recnsideratin frm a clinical peer reviewer. A prvider wh is treating a Member has the right t seek recnsideratin f an adverse determinatin frm a clinical peer reviewer in any case invlving an initial determinatin r a cncurrent review determinatin. This recnsideratin prcess shall be initiated within ne business day f the receipt f the request. It will be cnducted between the prvider and the clinical peer reviewer r a clinical peer designated by the clinical peer reviewer if the reviewer cannt be available. If the adverse determinatin is nt reversed by the recnsideratin prcess, the Member r the prvider n behalf f the Member, may pursue the grievance prcess established pursuant t New Hampshire RSA 420 J:5. The recnsideratin prcess allwed herein shall nt be prerequisite t the frmal internal grievance prcess r an expedited appeal required by New Hampshire RSA 420 J:5. Arranging a Telephne Cnference fr a Case Discussin r Recnsideratin T arrange a telephne cnference time fr a recnsideratin, the requesting physician shuld call Health Services at (Select Optin 4, then Optin 4). Health Services will btain the relevant plan infrmatin fr the case and arrange a telecnference between the requesting physician and the Minuteman physician reviewer r clinical peer reviewer. Care Management Minuteman s Care Management Prgram is designed t ffer physicians and Members a Nurse Care Manager t facilitate care crdinatin. Each Care Manager is respnsible fr perfrming utilizatin review and crdinating fllw up care. Care Management is prvided fr the ambulatry, utpatient and inpatient settings, as needed. Prviders may refer a Member fr Care Management Services by calling Minuteman Health Services at (Select Optin 4, then Optin 4). Minuteman prvides an After Hurs On Call Prgram. A Minuteman Care Manager is available t prviders and Members t assist in care crdinatin that ccurs utside f Minuteman s usual business hurs. The After Hurs On Call Prgram functins include: 1. Assisting prviders in transitining Members frm ne level f care t anther apprpriate level f care Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 40 f 69

41 2. Assisting in dispsitin planning fr hspitalized Members n weekends r hlidays where a delay may therwise be experienced 3. Being available t Members/families and prviders during transitins in care t answer questins Cmplex Case Management Cmplex Case Management is prvided fr thse Members wh have a high risk f hspitalizatin r require multiple health care services. The gal f Cmplex Case Management is t imprve the Member s functinal status, reduce hspital admissins, and reduce medical csts. If prviders have questins r wuld like t refer a Member t this prgram, prviders may cntact Health Services by calling (Optin 4, then Optin 4). Chrnic Cnditin Management Minuteman is cmmitted t helping ur Members with chrnic health cnditins live healthy lives. As part f this cmmitment, we ffer Chrnic Cnditin Management prgrams fr Members with: Diabetes Asthma Crnary artery disease High risk pregnancy COPD Heart Failure Depressin Hypertensin Minuteman partners with physicians in supprt f the plan f care. The verall gal f this cllabrative effrt is t help Members achieve and maintain cntrl f their cnditin by imprving self management skills. Minuteman prgrams prvide Members with educatin and supprt t help imprve their ability t manage their health cnditin n a day t day basis. Claims and encunter data are reviewed, using an algrithm, t identify Members with chrnic cnditins and stratify them int lw, medium, and high risk categries, based n the level f cntrl f their cnditin. Minuteman prvides interventins based n a Member s stratificatin level. Interventins include: Educatinal materials Questinnaires Health diaries Tracking tls Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 41 f 69

42 Telephnic assessment perfrmed by a registered nurse If prviders have questins r wuld like t refer a Member fr chrnic cnditin management, cntact Health Services at (Select Optin 4, then Optin 4). If a prvider wuld like mre infrmatin regarding disease management, case management r ther medical management functins please call Health Services at (Optin 4, then Optin 4). Health Infrmatin Line (HIL) The HIL prvides health infrmatin and resurces t Minuteman Members 24 hurs a day, 7 days a week. HIL, als knwn as the Nurse Advice Line, is nt intended t replace r questin the diagnsis f a physician r health care prvider, nr prvide specific fllw up care fr treatments prescribed. Fr triage situatins, the nurse directs the Member t the type f care mst apprpriate based n the symptms and situatin cnveyed by the Member. The HIL vendr ntifies Minuteman abut Member activity fr quality and utilizatin purpses. The HIL is accessible thrugh Minuteman s main telephne number r by dialing direct t Behaviral Health Cvered Services with Prir Authrizatin Minuteman cvers the fllwing services with prir authrizatin frm Health Services. Health Services cnducts cncurrent reviews f nging hspitalizatin services t ensure cntinued medical necessity. Behaviral Health/Substance Abuse Acute residential treatment (ART) Applied Behaviral Health Analysis Crisis Stabilizatin Unit Day treatment Partial hspitalizatin prgram (PHP) Family stabilizatin therapy (FST) Intensive utpatient therapy (IOP) Repetitive transcranial magnetic stimulatin (rtms) Neurpsychlgical testing Clinical Stabilizatin Services (CSS) and Acute Treatment Services (ATS) Members wh are denied cverage because f the absence f medical necessity will be ntified in writing. They will have the ptin t appeal thrugh Minuteman s Grievance Prcess, and will have the pprtunity t cntinue their treatment at their wn expense with either their Minuteman therapist r smene else f their chsing. If their Grievance is successful, the Medically Necessary treatment, including Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 42 f 69

43 the treatment received during the Grievance prcess, will be cvered. Shuld the clinical cnditin change, a new determinatin f medical necessity can be arranged by cntacting Health Services. Prviders will nt be penalized r terminated frm the netwrk fr advcating in favr f cverage fr a service r supply in accrdance with the terms f the Grievance prcess. What is Nt Cvered: Services that are nt cvered under the mental health/substance abuse benefit include: Educatinal services r testing, except services cvered under the benefit fr Early Interventin Services Psychanalysis Services fr prblems f schl perfrmance Nn licensed pastral cunseling/faith based cunseling Scial wrk fr nn mental health care Christian Science practitiner and sanitarium stays Services that a third party r curt rder requires, unless Minuteman determines that the service is Medically Necessary Hypnsis Telephne Therapy In Hme Therapy Residential/custdial services (including residential treatment prgrams, sber huses and halfway huses) Testing and treatment services at these facilities are nt cvered Diagnstic Imaging Management Prgram evicre/medslutins perfrms utilizatin management services fr utpatient imaging services n behalf f Minuteman. Certain radilgical services require prir authrizatin. This prir apprval plicy affects utpatient services nly; emergency rm, bservatin and inpatient imaging prcedures d nt require prir authrizatin. Failure t btain prir apprval may result in denial f payment. This plicy is applicable t all Minuteman Prducts. Prcedures that Require Prir Authrizatin and are required t be btained within the Minuteman Netwrk: CT Scan MRI/MRA PET Scan Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 43 f 69

44 Nuclear cardiac imaging (in ffice nly) Prir Authrizatin Prcess: Visit evicre/medslutins website belw r call The rdering physician is respnsible fr btaining the prir authrizatin frm evicre/medslutins fr the study requested. Patient symptms, past clinical histry and prir treatment infrmatin will be requested and shuld be available at the time f the call. evicre/medslutins als has the ability t receive yur requests nline via a secure web applicatin at The facility prviding radilgical services is respnsible fr ensuring that authrizatin has been btained prir t rendering service. Facility prviders may cnfirm authrizatins by visiting evicre/medslutin s website at Prviding services withut prir authrizatin may result in denial f payment. Call center hurs f peratin are Mnday thrugh Friday, 8:00 a.m. t 9:00 p.m. EST. Prviders may btain prir apprval by calling (Studies rdered after nrmal business hurs r n weekends shuld be cnducted by the rendering facility as requested by the rdering physician. Hwever, the rdering physician must cntact evicre/medslutins within 48 hurs f the next business day t btain prper apprval fr the studies, which will still be subject t medical necessity review.) Imprtant Ntes: If the rdering prvider is nt satisfied with evicre/medslutins decisin, the prvider may request a recnsideratin f the pre service denial. The prvider may request a recnsideratin by cntacting evicre/medslutins at The recnsideratin will be cnducted within ne business day f the request by the physician reviewer. If the prvider is still nt satisfied with the utcme after a recnsideratin, the prvider may initiate a Member appeal n behalf f the Member by cntacting Minuteman s Member Services Department at (Select Optin 4, then Optin 4). The Member must cnsent t the initiatin f the Member appeal. The prvider may submit a prvider appeal fr pst service denials. Accreditatin Requirements fr Advanced Diagnstic Imaging Facilities Suppliers f the technical cmpnent f advanced diagnstic imaging services must be accredited. Fr all lines f business, Minuteman fllws the Centers fr Medicare and Medicaid Services (CMS) accreditatin requirements fr suppliers that prvide the technical cmpnent f advanced diagnstic imaging. CMS defines advanced diagnstic imaging prcedures as including magnetic resnance imaging Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 44 f 69

45 (MRI), cmputed tmgraphy (CT), and nuclear medicine imaging such as psitrn emissin tmgraphy (PET). This requirement nly applies t the suppliers that furnish the technical cmpnent (TC) f advanced diagnstic imaging services, nt t the physicians interpreting them. Prviders subject t this requirement include physicians, nn physician practitiners, and Independent Testing Facilities. Hspitals are excluded frm this requirement. Clinical Transitin Prgram Minuteman has established a Clinical Transitin Prgram t ensure the cntinuity f care fr: New Members t Minuteman; New Members t Minuteman wh are actively receiving mental health services in accrdance with NH Admin Cde INS (b); Members wh have reached their benefit maximum fr cverage; Cntinuatin f cverage fllwing prvider disenrllment; and Departing Members withut new cverage. If prviders have questins cncerning prgram requirements and transitinal cverage available, prviders shuld cntact Minuteman Health Services by calling (Optin 4, then Optin 4). Apprpriateness f Care Statement It is the plicy f Minuteman that decisins regarding patient care are made based upn medical necessity, the apprpriateness f care, and the services rendered. If a service is nt medically necessary r is nt a cvered benefit, cverage may be denied. In cases where services are cvered but are nt being prvided, such as preventive care services and prenatal care, it is Minuteman s plicy t encurage apprpriate treatment. Bth apprval and denial f cverage are based n apprpriateness, medical necessity, and the scpe f Minuteman s cntractual bligatins t its Members. Minuteman des nt ffer incentives t its staff r t physician reviewers t encurage cverage denials, nr is cmpensatin tied t such denials. Medical Technlgy Assessment Prgram Minuteman uses Hayes Health Technlgy assessments t ensure that Members have equitable access t safe and effective care thrugh the evaluatin f develpments in new technlgy and new applicatins f existing technlgy. Technlgy evaluatin criteria, in general terms, include the fllwing: Apprval frm apprpriate regulatry bdies Scientific evidence must permit cnclusins cncerning the effect f the technlgy n health utcmes Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 45 f 69

46 The technlgy must imprve the net health utcmes The technlgy must be beneficial as an established alternative The imprvement must be attainable utside investigatinal settings If prviders have questins abut this prgram r wuld like Minuteman t cnsider cverage fr a new r existing technlgy, prviders shuld cntact Minuteman s MTAC Prcess Crdinatr, at , ext HIPAA Privacy Requirements and Patient Infrmatin Needed fr Utilizatin Management, Case Management and Care Crdinatin Minuteman cnducts utilizatin review, case management and care crdinatin activities fr payment and health care peratins purpses. In rder t perfrm these activities, Minuteman ften needs patient infrmatin such as ffice ntes, diagnstic results, and treatment plans. Sme physicians have expressed cncern abut whether they may disclse medical recrd infrmatin t Minuteman in light f the Privacy Rule requirements f the Health Insurance Prtability and Accuntability Act (HIPAA). HIPAA allws cvered entities, which includes physicians and health plans, t use r disclse prtected health infrmatin (PHI) withut an individual authrizatin frm the patient fr treatment, payment and sme health care peratin purpses, and fr certain ther specific purpses utlined by the HIPAA Privacy Rule. Cvered entities may disclse PHI t ther cvered entities fr the ther cvered entity s treatment, payment and health care peratin purpses, as defined by the Privacy Rule, as lng as the request relates t current r frmer patients r Members. Minuteman s utilizatin review activities are included under payment, and case management and care crdinatin activities are included within the limited health care peratin. Therefre, the disclsure f health infrmatin by a physician t Minuteman fr these purpses is permissible withut an individual authrizatin frm the patient under the HIPAA Privacy Rule. Minuteman recgnizes that health care prviders are cmmitted t cmplying with applicable privacy laws. Minuteman shares that same cmmitment and as a cmpany will prceed nly in a manner that is cnsistent with applicable laws, as utlined abve. Prviders shuld cntact the Minuteman Cmpliance Officer at if they have additinal questins r cncerns. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 46 f 69

47 CLAIMS SUBMISSION AND REIMBURSEMENT Scpe f Services The scpe f services fr which a prvider will be reimbursed is limited by the type f prvider agreement and the terms f that agreement. Reimbursement may be restricted t services within the prvider specialty, t services prvided at a specific lcatin, and t services specified in a particular Minuteman prduct s Evidence f Cverage (EOC). The scpe f cvered services prvided by physicians and allied health prviders is limited t the prvisin f prfessinal services, unless therwise specified in the prvider agreement and Minuteman payment plicy (please see Minuteman website fr mst up t date details). Thus, prviders will nly be paid fr the prfessinal cmpnent f their services, unless the prvider agreement expressly authrizes payment fr technical r ther services. Physicians and allied health prviders may request an expansin fr the prvisin f additinal cvered services by sending a letter f interest t Minuteman (please refer t fr cntact infrmatin). The request will be reviewed in cnsideratin f the needs f Membership fr such services in the prvider s gegraphic area, site f service, and the existing availability f similar services in that area. The apprval fr expansin f scpe f services will be made at the discretin f Minuteman and is subject t change with nt less than sixty (60) days prir ntificatin t the prvider. Claims Prcedure All claims must be submitted t Minuteman n either a CMS 1500 frm (frmerly HCFA 1500 frm) r a UB 04 frm (frmerly UB 92). All health care prviders and facilities must submit itemized claims t the Minuteman Claims Department, and claims will be subject t CMS prcessing guidelines including Crrect Cding Initiative (CCI) edits. Claims must be submitted t Minuteman within ne hundred eighty (180) days f the date f service r date f discharge frm a facility (r, in the case f a claim subject t COB with anther payer, within six mnths f the date f payment r denial by the primary carrier) r within the time perid specified by cntract. If a bill is nt received by Minuteman within the specified time perid, it will be denied fr exceeding the claims filing limit. Prviders may nt bill Members fr services that were denied payment fr untimely submissin. The filing limit als applies t the resubmissin f claims. If a claim is denied fr incrrect cde, etc., and the prvider resubmits the claim with the crrect infrmatin, it must be received at Minuteman within the filing limit f the riginal date f service. Prviders als shuld be aware that the filing limit applies when utilizing the services f a billing agent. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 47 f 69

48 Claims Xten Edits Minuteman prcesses all claims using the claim editing sftware Claims Xten frm McKessn, which reviews claims in a payable status and applies recmmended mdificatins based n cmmn cding guidelines established by the Centers fr Medicare and Medicaid Services (CMS). If a service is edited, Minuteman will prvide an adjustment cde with the Explanatin f Payment. Imprtant Infrmatin Regarding All Claims All claims must include this infrmatin: Patient name (as it appears n the Member s Minuteman ID card) Minuteman Member ID number (including applicable letter prefix and tw digit number suffix as it appears n the Member s Minuteman ID card) Mst current ICD 9 CM cdes, using apprpriate 3, 4 r 5 digit cdes (If there is mre than ne diagnsis, it is imprtant t include all apprpriate ICD 9 CM cdes.) Date(s) f service Standard place f service cde Descriptin f service(s), using, as apprpriate, the mst current CPT prcedure cde(s), UB 92 revenue cde(s), HCPCS cde(s), r unique cdes previusly agreed upn by Minuteman Prvider name, payment address, Minuteman Prvider number (if pssible), prvider signature, and prvider federal tax identificatin number and Prvider NPI number Infrmatin regarding ther insurance cverage Name f the referring r rdering physician Units Amunt billed fr each prcedure Ttal f all amunts billed Reprts (if applicable t describe unusual services r services fr which a cding methdlgy des nt exist) Minuteman will accept claim submissin in the fllwing frmats: Electrnically: HIPAA cmpliant prfessinal (CMS1500) HIPAA cmpliant institutinal (UB 04) Paper claim: CMS 1500 fr prfessinal Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 48 f 69

49 UB 04 fr facility r technical EDI Claims Submissin The fllwing infrmatin must appear n all electrnic claims: The crrect Minuteman Prvider 5 digit number in the PIN field The crrect Minuteman Member 11 digit ID number The Minuteman Payer Number: Fr mre detailed infrmatin, please g t: prfessinals Place f Service Cdes Cde Descriptin Cde Descriptin 11 Office 41 Ambulance Land 12 Hme 51 Inpatient Psych Facility 21 Inpatient Hspital 52 Psychiatric Facility/Partial Hspitalizatin 22 Outpatient Hspital 53 Cmmunity Mental Health Center 23 Emergency Rm Hspital 54 Intermediate Care Facility/Mentally Retarded 24 Ambulatry Surgical Center 61 Cmprehensive Inpatient Rehab Facility (CIRF) 25 Birthing Center 65 End Stage Renal Disease 31 Skilled Nursing Facility 71 Public Health Clinic 32 Nursing Facility 81 Independent Lab 34 Hspice 99 Other The abve table is a partial listing f the cde set referenced under HIPAA. The mst recent versin f this cde set can be fund n line at f servicecdes/place_f_service_cde_set.html Nn participating prviders can use any valid place f service cde. Cntractual agreements with participating prviders may include/exclude cdes frm this cde set. Paper Claims Minuteman prefers that all claims be submitted electrnically. In instances where paper must be used, Minuteman uses an imaging and capture prcess fr paper claims. T ensure accurate and timely claims imaging, please fllw the rules belw: Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 49 f 69

50 Type all fields cmpletely. Submit all claims n an riginal red and white frm. Cmplete all claims in black r blue ink nly. Include the wrd cntinue when submitting a multi page paper claim with the ttal amunt n the last page. (D nt sub ttal the first page). D nt use highlighter n any claim frm field. D nt submit pht cpied claim frms. D nt submit claim frms via fax. D nt submit unnecessary attachments. Paper Claims need t be submitted t the fllwing address: Minuteman Health C/ Health New England One Mnarch Place, Suite 1500 Springfield, MA Clean Claim Requirements The fllwing fields are required fr UB 04 & CMS 1500 claim frms. CMS 1500 (Physician Claims) Patient s Name Patient Minuteman ID Number Patient s DOB and Gender Patient s Address Other Insurance / Wrkers Cmpensatin / MVA Insured s Plicy Grup r Number Insured s Name and Address Prvider s Name & Prvider ID Number Prvider s Address Practice Tax ID Number (EIN) Service Date(s): T and Frm Place f Service (CMS Cdes) Prcedure Cde (CPT 4; HCPCS Current, valid cdes) Diagnsis Cdes (ICD 9 up t 5th digit if applicable Current, valid cdes) Units Amunt Billed fr Each Prcedure Attending Physician Patient Accunt Number (ptinal) Ttal f All Amunts Billed Prvider s Telephne Number Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 50 f 69

51 Prvider s NPI Number Mdifier Cdes (CPT 4, HCPCS Current, valid cdes) UB 04 (Facility Claims) Patient Name Patient Minuteman ID Number Patient s DOB and Gender Patient s Address Other Insurance / Wrkers Cmpensatin /MVA Insured s Plicy Grup r Number Insured s Name and Address Date Prvider s Name, Prvider ID Number Prvider s Address Prvider s Telephne Number Practice Tax ID Number (EIN) Type f Bill Claim Statement Dates Prvider s NPI Number Service Date(s): T and Frm fr Entire Service S Date(s) fr Each Service Outpatient Revenue Cdes (Current, valid cdes) Prcedure Cde (CPT 4; HCPCS Current valid cdes) Outpatient Only Units Anesthesia Claims require Minutes Amunt Billed fr Each Service Ttal f All Billed Amunts Principal Diagnsis Cde (ICD 9 up t 5th digit if applicable) (Current, valid cdes) Secndary/Other Diagnsis Cde(s) (ICD 9 up t 5th digit if applicable) (Current, valid cdes) Attending Physician ICD 9 Prcedure Cde(s) Principal and All Other Applicable Cdes Admissin Date (ptinal fr utpatient; required fr inpatient) Admissin Hur (ptinal fr utpatient; required fr inpatient) Discharge Hur Discharge Status POA Indicatrs Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 51 f 69

52 Minuteman Prvider Cllectin Plicy Minuteman recmmends that the prvider submit the bill t Minuteman prir t cllecting any prtin f a Member s deductible and cinsurance. If a prvider cllects frm the Member prir t submitting a bill t Minuteman, we expect prviders and Members t crdinate mutually acceptable terms fr cllectin f a Member s deductible and cinsurance bligatins. In n event may a prvider cllect payment frm a Minuteman Member fr a Minuteman cvered service fr mre than the Member s current estimated remaining deductible bligatin as f the date f service. In the event that an amunt in excess f a Member s actual bligatin is inadvertently cllected, the prvider r facility must prmptly remit such excess amunt t the Member upn verificatin frm the prvider s r facility s EOP r Member s EOB. Minuteman supprts the use f standardized disclsure and authrizatin frms t facilitate dialgue between prviders and Members regarding financial respnsibility and t establish expectatins and facilitate cllectin f Member deductible and cinsurance payments. In all cases, Minuteman expects prviders r facilities t apply cllectin practices that are n mre restrictive t Minuteman Members than thse applied t Members f any ther cmmercial payers. Additinal Requirements fr Out f Netwrk High Cst Claims Any ut f netwrk prvider wh requests reimbursement fr services equal t r greater than $10,000 must submit (1) an itemized listing f charges and (2) the cmplete medical recrd as part f the claim fr reimbursement. Any prvider that fails t prvide this infrmatin will have its request fr reimbursement pended fr 30 days until such dcumentatin is prvided. If the prvider fails t prvide the required dcumentatin within that 30 day perid, the claim will be denied. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 52 f 69

53 Sample Statement f Understanding Nte: Use the fllwing Statement f Understanding frm fr services that Minuteman will nt cver and fr which the Member intends t accept full financial liability. If yur ffice uses a different Statement f Understanding, it shuld be substantially similar t the frm belw. This frm shuld nly be used in ne f the fur circumstances described n the frm belw. Member Assumptin f Financial Respnsibility fr Medical Services Statement f Understanding I understand that a Minuteman prvider may nt require me t sign this Statement f Understanding as a cnditin f receiving services unless ne r mre f the fllwing cnditins exist n the date belw (date services prvided): 1. These services are nrmally prvided by my primary care prvider and I have decided t request services frm the belw named prvider wh is nt my primary care prvider, r 2. These services exceed my benefit limitatin, r 3. These services are nt cvered services under my Plan, r 4. These services have nt received prir apprval. I acknwledge that I have vluntarily sught the services f (name f prvider) wh is a Minuteman participating prvider. I accept full respnsibility fr paying fr these services prvided tday by the abve named prvider. I understand that Minuteman will nt pay the prvider, r reimburse me, fr the cst f tday s services, r any subsequent r ancillary medical services that the prvider may rder tday n my behalf as a result f tday s visit. I understand that this Statement f Understanding is nt an acceptance f financial respnsibility fr any services ther than thse services prvided r rdered tday. Patient s Name (please print r type) Patient s Minuteman Member ID Number Patient s Signature Tday s Date Parent/Guardian Signature (if under 18 years f age) Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 53 f 69

54 Crdinatin f Benefits Crdinatin f Benefits (COB) ccurs when Minuteman arranges fr payment frm an alternative insurance, which may either be primary r secndary fr the claim. When a Member is cvered under tw different plans, Minuteman crdinates benefits under each plan accrding t rules used thrughut the insurance industry r as required by law. Explanatin f Payment (EOP) These reprts can be fund n the Minuteman prvider prtal at Paper EOP s will nw be accessed thrugh the prvider prtal fr ur In Plan Prviders. DME Billing Guidelines and Prcedures DME Vendrs Only Mdifiers Every DME item billed with an A, E, L, r K HCPCS cde must be billed with a mdifier. NU is required fr items which are purchased and are never rented RR is required fr any item that is rented fr the billed perid NR is required fr any item that has been rented previusly fr the designated number f rental perids and is being purchased in the current billed perid If a DME item is billed by a DME r rthtics and prsthetics vendr withut a mdifier, the claim will be denied. DME Vendrs Only SC Mdifier Minuteman will reimburse higher than the standard rate fr cvered, nn standard, medically necessary items when the Member presents a prescriptin fr the nn standard item. The vendr shuld bill the HCPCS cde crrespnding t the standard item and attach an SC mdifier. Rather than the standard reimbursement, Minuteman will reimburse the vendr a percent f the billed charge based upn the default percent f charge listed in the vendr s cntract. Minuteman reserves the right t audit the vendr s prescriptins fr any item which Minuteman has been requested t reimburse. Please nte: When an SC mdifier is used with HCPCS cde E1399 (Miscellaneus), reimbursement will be accrding t the E1399 guidelines belw, which apply t DME vendrs nly: Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 54 f 69

55 When shuld a DME item be billed with HCPCS cde E1399? The HCPCS Manual describes E1399 as Durable medical equipment, miscellaneus. Therefre, this cde shuld nly be used t bill fr DME fr which n presently active HCPCS cde accurately describes the DME item. When will Minuteman prvide reimbursement fr a DME item billed with E1399? Minuteman will prvide reimbursement fr a DME item billed with E1399 when the item is cvered under the vendr s cntract, is cvered by the Member s benefit, and is medically necessary r therwise authrized by Minuteman Health Services in advance. What are the guidelines fr prcessing DME items billed with E1399? The DME item will be denied as billed incrrectly if it is billed with E1399 when a mre precise, descriptive HCPCS cde exists. A DME item billed with E1399 fr a ttal charge (including multiple units) f less than r equal t $300 will be reimbursed at the prvider s cntracted default discunt rate. If a DME item with ttal charges (including multiple units) greater than $300 fr cde E1399 is submitted n a claim, it must be accmpanied by an invice. The claim and invice will be reviewed and a payment determinatin made. Special Instructins fr DME Vendrs Wh Bill Electrnically: DME vendrs wh bill electrnically must submit paper claims with an invice fr any DME items billed with E1399 fr ttal amunts greater than $300, therwise the claim will be denied as billed incrrectly. Physicians Only Mdifiers There are n mdifier requirements fr physicians billing fr DME. Minuteman s Vaccine Plicy State Supplied Vaccines in General: All State Supplied Vaccines are cnfigured in ur system fr specific age ranges. Claims fr Members receiving a vaccine n the State Supplied list whse age is utside f the Statespecified age range will be pended fr review. Minuteman will cntact the prvider t cnfirm the fact that the vaccine was purchased and nt supplied free frm the State. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 55 f 69

56 IN ALL OTHER INSTANCES, STATE SUPPLIED VACCINES ARE NOT COVERED: Minuteman expects prviders t get these frm the State. Minuteman expects prviders t give the State Supplied vaccines n the apprved schedule (CDC and AAP). Other Vaccines: Minuteman will cver supplied vaccines fr Minuteman Members under the fllwing cnditins: The physician must bill fr the vaccine using the apprpriate J cde r CPT cde (this allws vaccines t be cnsidered a preventive service fr High Deductible Health Plans). The physician may purchase the vaccine thrugh any supplier (as lng as it is nt State Supplied). Minuteman will reimburse the physician using the Minuteman fee schedule, which is updated quarterly. HEDIS reprts fr prviders The Health Plan Emplyer Data and Infrmatin Set (HEDIS) is the mst widely used set f perfrmance measures in the managed care industry. HEDIS is designed t ensure that purchasers and cnsumers have the infrmatin they need t cmpare the perfrmance f managed care plans. Minuteman requires all prviders t cperate in the cllectin f data fr HEDIS reprting. HEDIS cntains 61 measures acrss 8 dmains f care: Effectiveness f Care Access/Availability f Care Satisfactin with the Experience f Care Health Plan Stability Use f Services Cst f Care Infrmed Health Care Chices Health Plan Descriptive Infrmatin Payment Plicies Minuteman s payment plicies are intended t help with the claim submissin prcess by detailing accurate cding and benefit cverage. Minuteman s payment plicies are lcated at prfessinals/prvider frms dcuments. Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 56 f 69

57 PROVIDER APPEAL GUIDELINES Nte: These guidelines d nt apply t the submissin f an amended claim t a previusly prcessed claim within 180 days frm date f service. An amended claim submitted within 180 days is an On Time Crrected Claim and nt a Prvider Appeal. Please nte n the claim frm that it is an On Time Crrected Claim and mail it t: Minuteman Claims Department, One Mnarch Place, Suite 1500, Springfield, MA On Time Crrected Claims cannt be accepted via fax. Please fax Prvider Appeals t Minuteman at: Prvider Appeal Guidelines: Prviders have the right t file a Prvider Appeal if they disagree with hw Minuteman prcessed a claim. Prvider Appeals must be submitted within sixty (60) calendar days f the date f claim adjudicatin r the appeal will be denied. A Prvider Appeal must be submitted n the Request fr Claim Review frm, which can be fund n the fllwing page and under the Prvider Frms sectin n the Minutemen website. The cntrl number the 12 digit number n the Minuteman Explanatin f Payment (EOP) must be listed n the Request fr Claim Review frm. Please include with yur appeal: The EOP and all supprting dcumentatin, such as perative and ffice ntes, authrizatins, invices, and ther infrmatin which wuld be pertinent t the review prcess, ratinale fr appeal, and desired reslutin. PLEASE NOTE: If yu are disputing a denial f a Prir Authrizatin Request and the service has nt yet been rendered, yur appeal will be treated as a Member Appeal and prcessed in accrdance with Minuteman s Member Appeal Guidelines. Appeal Types: Prvider Cntractual Appeals, such as Claim denied fr n authrizatin Claim denied past filing limit Claim denied as billed incrrectly Claim denied as duplicate claim Claim reimbursement issue, e.g. CPT cde(s), disagreement abut payment methdlgy Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 57 f 69

58 Prvider Adverse Determinatins (relates t decisins made during the prir authrizatin prcess that impact hw a claim has been prcessed), such as Claim denied fr nt being medically necessary Claim denied as experimental/investigatinal Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 58 f 69

59 MINUTEMAN CLINICAL GUIDELINES AND STANDARDS Clinical Guidelines and Standards The Minuteman Quality and Utilizatin Management Cmmittee (QUMC) is respnsible fr develping, disseminating and crdinating activities intended t define gd medical practice and develp imprved quality. Activities include establishing and maintaining a criterin based system including standards and guidelines in relatin t patient care and develping pre treatment and pre admissin medical prtcls. Clinician participatin plays an imprtant rle in the develpment f clinical guidelines and standards. Participating clinicians serve n the QUMC, and Minuteman welcmes and invites the cmments f ther participating clinicians. If prviders have cmments, questins, r cncerns abut a clinical guideline r standard, they shuld cntact the Minuteman Directr f Quality & Medical Management at Prviders are required t cperate with all Quality Imprvement and Assurance activities t imprve the quality f care, services and member experience. This includes allwing the cllectin and evaluatin f prvider data. Unless new scientific evidence r revised natinal standards warrants review and update sner, clinical guidelines are reviewed biennially. Preventive health recmmendatins are reviewed annually. All clinical guidelines, standards, quality prgram and criteria used fr rendering decisins regarding the apprpriateness f medical services are available t participating prviders upn request by calling Health Services at (Select Optin 2 then Optin 4). In additin, internally develped clinical guidelines are available n the Minuteman website at Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 59 f 69

60 Medical Recrd Standards and Reviews The fllwing minimum medical recrd standards will be used fr quality assurance purpses: Revised 11/21/2017 MHI New Hampshire Prvider Manual Page 60 f 69