Provider Network Fax Blast
Monday, July 18, 2016
2 Executive Park Drive
Bedford, NH 03110
Ambetter from NH Healthy Families is publishing its Payment and Clinical Policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that Ambetter from NH Healthy Families currently employs.
The Health Plan believes that publishing this information will help providers to bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments. However, once these policies have been published, some providers will observe claims processing edits that assure only accurately and appropriately coded and billed services are reimbursed.
The nature of these policies addresses coding inaccuracies including diagnosis to procedure code mismatch, inappropriately modified procedures, unbundling, incidental procedures, duplication of services, non-covered services and health plan specific payment rules for procedures and services. These policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology
(CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state of New Hampshire or regulations.
Determinations for non-payment or reduced payments are based upon the resources listed previously for which the provider is liable, and do not represent opportunities for providers to balance bill patients. The American Medical Association (AMA) in conjunction with multiple specialty societies, CMS and representatives from multiple health care insurers maintain and update the CPT® codes, and establish the rules for the proper use of the CPT and other procedure codes. Guidelines governing the use of the codes and modifiers are clearly delineated in the CPT annual publications as well as other supporting documents published by the AMA. CMS further clarifies and defines the proper use of codes, combinations of codes as well as the combinations of codes and modifiers in multiple publications and databases. Coverage provisions are adopted from specialty society guidelines, the published peer reviewed medical literature, Medicare policy, and local standards of medical care.
Ambetter from NH Healthy Families takes the responsibility of detecting fraudulent, wasteful and inaccurately or inappropriately billed claims very seriously. These improvements to our detection activities will enable us to more effectively prevent incorrect payment of claims and provide equitable reimbursement to all providers. We are aware that these improved procedures will impact some claims payments for providers, and there will be a period of adjusting to the implementation of these policies. We are committed to being fair and consistent to providers, patients, and our clients as we pursue our goal of ensuring correct payment of healthcare claims.

Provider Network Fax Blast
Monday, July 18, 2016
2 Executive Park Drive
Bedford, NH 03110
The effective date for the below policies is September 15, 2016.
Policy Name
Wheelchair
Accessories
Ambulatory
EEG
3-Day Payment
Window
Policy Description
Aims to ensure that payment for the technical component of all outpatient diagnostic services and related non-diagnostic services are bundled with the claim for an inpatient stay when services are furnished within 3 calendar days.
Paclitaxel Protein-bound paclitaxel is a specialty drug used to treat seven types of cancer; standard paclitaxel is used to treat a broader range of cancer types. The policy aims to establish guidelines for using protein-bound paclitaxel according to approved standards of care.
Allergy Testing The policy outlines the payment rules for allergy tests and immunotherapy treatments. It aims to incentivize providers to order tests only when necessary.
Avastin
(Bevacizumab)
Bevacizumab is a specialty drug used for the treatment of certain types of cancer and specific ophthalmologic indications. The policy aims to limit the payment for these drugs to
FDA-labeled and efficacious off-label treatments only.
Defines bundling guidelines for wheelchair options and accessories when they are included in the cost of a base wheelchair.
Ultrasound in
Pregnancy
An ambulatory EEG is a test used for the diagnosis and classification of seizures. The use of this test is still considered investigational for any other indication. The policy aims to limit payment for Ambulatory EEGs only for indications where medical necessity has been established.
This policy outlines the medical necessity criteria for ultrasound use in pregnancy.
Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location; and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.
Urodynamic
Testing
Wheelchair
Seating
Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The purpose of this policy is to define the medical necessity criteria and coding guidelines for commonly used urodynamic studies.
Outlines appropriate coding and clinical criteria for the payment of wheelchair seating and accessories.
Please contact Provider Services at 1-866-769-3085 with any questions about the policies.
Thank you,
NH Healthy Families