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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the NH Healthy Families Clinical Policy Manual apply to NH Healthy Families members. Policies in the NH Healthy Families Clinical Policy Manual may have either a NH Healthy Families or a “Centene” heading.  NH Healthy Families utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a NH Healthy Families clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling NH Healthy Families. In addition, NH Healthy Families may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by NH Healthy Families.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Clinical Policies

Medicaid Specialty Pharmacy Policies

 

 

 

NH Healthy Families is pleased to announce its collaboration with New Century Health (NCH), an oncology quality management company, to implement a new oncology pre-approval program, NH Healthy Families Oncology Pathway Solutions. The program will simplify the administrative process for providers to support the effective delivery of quality patient care.

Beginning May 1, 2020, all oncology-related chemotherapeutic drugs and supportive agents will require clinical review by NCH before being administered in a physician’s office, outpatient hospital or ambulatory setting. This prior authorization requirement applies to both pharmacy dispensed and office administered medication requests for all NH Healthy Families Medicaid members ages 18 and over.

NH Healthy Families Oncology Pathway Solutions program benefits include:

  • The use of clinical criteria, based on nationally-recognized guidelines, to promote evidence-based cancer care.
  • Increased collaboration with physician offices to foster a team approach.
  • Peer-to-peer discussions with medical oncologists who can understand and better discuss treatment plans.
  • A provider web portal to:
    • Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
    • Determine which clinical documentation is necessary for medical necessity review.
    • View all submitted requests for authorization in one location.
    • Check member eligibility.

Pre-approval Process

  • The requesting physician must complete an authorization request using one of the following methods:

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the NH Healthy Families Payment Policy Manual apply with respect to NH Healthy Families members. Policies in the NH Healthy Families Payment Policy Manual may have either a NH Healthy Families or a “Centene” heading.  In addition, NH Healthy Families may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by NH Healthy Families.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Ambetter Payment Policies

Medicaid Payment Policies