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Prior Authorization

Please note, failure to obtain authorization may result in administrative claim denials. NH Healthy Families providers are contractually prohibited from holding any member financially liable for any service administratively denied by NH Healthy Families for the failure of the provider to obtain timely authorization.

Check to see if a pre-authorization is necessary by using our Prior Authorization Prescreen Tool.

Expand the links below to find out more information.

As the Medical Home, PCPs should coordinate all healthcare services for NH Healthy Families members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Some services require prior authorization from NH Healthy Families in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least fourteen (14) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

NH Healthy Families’s Medical Management department hours of operation are Monday through Friday from 8:00 a.m. to 5:00 p.m. (CST) (excluding holidays). After normal business hours, Envolve nurse line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

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: