Neighborhood Health Providers

Referrals to Network Specialists

PCPs must use the Referral Voucher Form to refer members to network specialist providers. Prior approval is not needed from NHP for referrals from PCPs to NHP network specialists, physical therapy and occupational therapy. Specialist can use referral form only for DME, Orthotics and Prosthetics less than $250. A specialist or OB/Gyn that wants to refer a member to another specialist must ask PCP to complete a referral form. The PCP does not have to see the member again, can complete referral form after phone consultation with first specialist.

Hospital

Admissions

Elective admissions ≠ prior approval required -call NHP UM at 1-800-765-3805 or FAX information to 1-800-338-4195 ≠ at least 7 days prior to admission. Admitting network specialist providers must have a Referral Voucher Form from the PCP (if the admitting provider is not the PCP).

Emergency & Maternity admissions ≠ notification required - call NHP UM at 1-800-765-3805 or FAX notification to 1-800-338-4195, within 24 hours or next business day.

A Referral Voucher Form is not needed for inpatient consultations.

Emergency Room Visit

No prior approval is needed from NHP. No notification requirement. Based on diagnosis, either the emergency room rate is paid or a request is made to the hospital to submit the medical record. If the medical record is not received within 45 days, the triage rate is paid.

OB/GYN

No prior approval is needed from NHP or referral from PCP for routine in network OB/GYN visits. OB/GYNs do not need prior approval to order in network diagnostic tests except MRIs and stress tests. See NY State regulations or Provider Manual for more details. Prenatal providers must notify NHP of all pregnancies using the Pregnancy notification form (available by calling Provider Services).

Family Planning

No prior approval is needed from NHP or referral from PCP for Family Planning visits. Medicaid members can ≥self refer≤ to any Medicaid provider. CHP and FHP members must use a network provider. Elective abortion is covered.

Health Promotion Visits

No prior approval is needed from NHP for well adult, child and adolescent care visits. Primary care encounter data must be submitted to NHP.

Diagnostic Laboratory Tests & X-rays

No prior approval or referral is needed from NHP for use of an in network facility or radiologist. Hospital/health center affiliated PCPs must use the hospital/health center laboratory and radiology services.

Private office PCPs can use any private lab and any contracted radiology provider. NHP will pay the Medicaid rate to the lab.

Other Outpatient Diagnostic Tests

A referral form is not needed for any other diagnostic tests including EEG, EMG, PFTs, MRI etc. if performed at a participating facility. Diagnostic tests being in a

non-participating facility, or by a non-participating PCP or non-participating specialist, the provider must call NHP UM at 1-800-765-3805 for prior authorization.

Therapeutic

Services

Prior approval is required by NHP for cardiac rehabilitation, ambulatory radiation therapy, chemotherapy and hemodialysis - call NHP UM at 1-800-765-3805.

Nutrition Counseling

Nutrition counseling provided at NHP Health Centers is included in the primary care capitation -- no separate approval is required and there is no separate reimbursement.

Obesity Surgery

Prior approval is required by NHP.

The PCP or specialist must contact NHP UM at 1-800-765-3805. The NHP Medical Director reviews all requests. (e.g., gastric stapling)

Second Medical Opinion

No prior approval or authorization is needed from NHP for in-network service.

PCPs must use the Referral Voucher Form to refer members to qualified network specialist providers for covered services. A second medical opinion is available in the event of a positive or negative diagnosis of cancer, a recurrence of cancer, or a recommendation of a course of treatment of cancer.

Second Surgical Opinion

No prior approval or authorization is needed from NHP for in-network service.

PCPs must use the Referral Voucher Form to refer members to qualified network specialist providers for a second opinion for surgery.

Pre-surgical &

Pre-admission

Testing

No separate approval is needed from NHP. PCP completes Referral Voucher Form for surgeon/admitting provider. Hospital preauthorizes inpatient stay.

Includes tests (laboratory, x-ray, etc.) necessary to inpatient or outpatient surgery or other elective inpatient admission. Benefits are available if a physician orders the tests; proper diagnosis and treatment require the tests; and the surgery/admission takes place within 7 days after the testing.

Ambulatory Surgery

PCPs must use the Referral Voucher Form to refer members to network specialist providers for surgery. No prior approval is needed from NHP ≠ with the exception of certain procedures that are potentially cosmetic in nature. A list of these procedures is in the Appendix to the Provider Manual. If the member is admitted to a hospital, the hospital or provider must call NHP UM at 1-800-765-3805.

Behavioral Health Services

∑ substance abuse (drug & alcohol)

∑ mental health

Providers must call Magellan Behavioral Health (MBH) for emergency admission notification and for precertification of elective admissions. No referral from PCP or prior approval needed from NHP. Medicaid members can ≥self refer≤ directly to any Magellan Behavioral Health provider for the first outpatient visit. Member must use MBH network. Members may call MBH directly (24 hours/day) at 1-800-318-2696 to access services. Or, providers may assist members and call MBH to arrange services.

Note: CHP and FHP members have service limitations. Inpatient services are covered for a combined 30 days per calendar year for inpatient mental health services, inpatient detoxification and inpatient rehabilitation. Outpatient services are limited to an aggregate of 60 visits per calendar year. Visits may be for family therapy if visits are related to alcoholism or substance abuse.

Home Health Care

Prior approval is required by NHP.

The PCP, authorized referral specialist or home care agency must call 1-800-765-3805 or FAX NHP UM at 1-800-270-3447. Members must use a NHP participating Home Health Care Agency.

Note: CHP and FHP members have a 40 visit per calendar year limitation.

Physical, Respiratory, Occupational, and Speech Therapy

Prior approval is required by NHP except for the first visit for evaluation by a Speech Therapist. For continuing speech therapy, the PCP, therapist or authorized referral specialist must call NHP UM at 1-800-765-3805. For physical and occupational therapy only a referral voucher form is required.

Note: NHP covers therapy when a physician, in order to significantly improve, develop or restore physical conditions lost or impaired as a result of disease, injury or surgical procedure, prescribes the care. Only short-term physical therapy will be covered when the member is likely to gain significant improvement from the therapy applied over the prescribed time frame. For CHP and FHP outpatient PT visits are limited to 20 per calendar year and outpatient OT visits are limited to 20 per calendar year. For CHP and FHP covered speech therapy services are those required for a condition amenable to significant clinical improvement within a 2-month period beginning with the first day of therapy.

Durable Medical Equipment (DME)

Prior approval is required by NHP for items > $250 or on list in Provider Manual. The PCP, DME vendor or authorized referral specialist must call NHP UM at 1-800-765-3805. Items less than $250, the PCP or authorized referral specialist must complete the Referral Voucher Form (or call UM if unsure). Members must use a participating provider.

Exclusion: Glucose monitors do not require prior authorization and are billed to Medicaid FFS for Medicaid Managed Care. For CHP and FHP, glucose monitors are covered under the DME benefit and does require prior authorization by NHP UM at 1-800-765-3805.

Note: For CHP, DME is limited to hospital beds and accessories, oxygen and oxygen supplies, pressure pads, volume ventilators, therapeutic ventilators, nebulizers and other equipment for respiratory care, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts, nutrition infusion pumps, and ambulatory infusion pumps. DME coverage includes equipment servicing (labor and parts).

Orthotics and Prosthetics

Prior approval is required by NHP for items > $250. The PCP, vendor or authorized referral specialist must call NHP UM at 1-800-765-3805.

Other items - the PCP or authorized referral specialist must complete the Referral Voucher Form (or call Precertification if unsure).

Members may use any vendor; NHP will pay the Medicaid rate for services.

Note: CHP members have service limitations.

Vision Services

∑ well eye exams

∑ vision screening

∑ glasses

∑ other medically necessary eye care goods

No prior approval is needed from NHP. No referral form is needed. Members can ≥self refer≤ to any DAVIS VISION network provider for a well vision exam every 2 years and must use the DAVIS VISION network.

Call DAVIS VISION at 1-800-999-5431 for the name of a participating provider.

Hearing

Services

PCPs do not have to complete a separate referral for in-network hearing exams. A referral to an ENT specialist provider covers hearing tests conducted by the specialist or audiologist at the same site as the ENT provider.

For Hearing Aids prior approval is NOT required. Members may use any vendor. NHP will pay the Medicaid rate for services.

CHP Benefit- One hearing examination per calendar year is covered. Hearing aids including batteries and repairs are covered. Audiometric testing is covered when medically necessary.

Podiatry

The PCP must complete a Referral Voucher Form to a network Podiatrist. The referral must be for medically necessary services; not routine foot care. Members must use a NHP network podiatrist.

Transportation

Medicaid Providers should use their established vendor relationships for ambulance, ambulette or livery service. NHP providers handle the distribution of metrocards utilized by members. Logs are sent to NHP for reimbursement of the expense of metrocards distributed.

Note: For CHP members, neither emergency nor non-emergency transportation is covered. For FHP members, only emergency transportation is covered.

Pharmacy

(CHP and FHP Only)

NOTE:

Medicaid members must use their Medicaid card.

CHP and FHP members must use an NMHCRx (formerly Centrus) pharmacy, except in an emergency.

Formulary is used for specific therapeutic drug classes. Prescriptions may be limited to generic medications where medically acceptable. Includes family planning or contraceptive medications or devices. Medications used for preventive or therapeutic purposes are covered. Vitamins are not covered except when necessary to treat a diagnosed illness or condition. Coverage includes enteral formulas for home use for which a provider authorized to prescribe has issued a written order. Enteral formulas for the treatment of specific diseases are distinguished from nutritional supplements taken electively. Coverage for certain inherited diseases of amino acid and organic acid metabolism include modified solid food products that are low protein or which contain modified protein. Coverage for such modified solid food products will not exceed $2500 per calendar year.

Dental services

NHP has an exclusive contract with Healthplex to provide specific ambulatory dental services to NHP members. Providers or members can call Healthplex 1-800-468-9868

Medical Supplies

Coverage for medical supplies is limited under CHP; see diabetic supplies and home care. Disposable medical supplies are not covered by FHP. Medicaid members must use their Medicaid card to obtain medical supplies.

Diabetic

Supplies &

Equipment

Medicaid-Supplies covered under fee for service Medicaid. Members should use their Medicaid card. Glucose monitors do not require prior authorization and are paid by Medicaid FFS for Medicaid Managed Care only. Equipment covered under NHP DME benefit.

CHP and FHP covered diabetic DME and supplies include: blood glucose monitors, blood glucose monitors for legally blind, data management systems, test strips for monitors and visual reading, urine test strips, injection aids, cartridges for legally blind, syringes, insulin pumps and appurtenances thereto, insulin infusion devices, and additional equipment and supplies designated by the Commissioner of Health as appropriate for the treatment of diabetes.

Diabetic

Education &

Home Visits

Medicaid- Services through NHP participating Home Health Agencies. CHP Benefit-Coverage includes diabetes self-management education (including diet); re-education or refresher; home visits for diabetic monitoring and/or education. Limited to medically necessary visits where a physician diagnoses a significant change in a memberπs symptoms or conditions that necessitate changes in a patientπs self-management or where re-education is necessary. May be provided by a physician or other licensed health care provider legally authorized to prescribe as part of an office visit for diabetes diagnosis or treatment, or by a certified diabetes nurse educator, certified diagnostic nutritionist, certified or registered dietician upon the referral of a physician or other licensed health care provider legally authorized to prescribe and may be limited to group settings wherever practicable.

Referrals to out of network specialists and other out of network providers

Prior approval is required by NHP. Permitted if NHP does not have a network provider of needed specialty. The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Standing referrals to network specialists

Prior approval is required by NHP. Permitted for members who need ≥ongoing care.≤ The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Standing referrals to out of network specialists

Prior approval is required by NHP.

Permitted for members who need ≥ongoing care≤ and if NHP does not have a network provider of needed specialty. The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Network specialists as PCPs

Prior approval is required by NHP.

Permitted for members with a ≥life threatening≤ or ≥degenerative and disabling≤ condition or disease. The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Out-of-network specialists as PCPs

Prior approval is required by NHP.

Permitted for members with a ≥life threatening≤ or ≥degenerative and disabling≤ condition or disease and if NHP does not have a network provider of needed specialty. The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Referrals to network specialty care centers

Prior approval is required by NHP.

Permitted for members with a ≥life threatening≤ or ≥degenerative and disabling≤ condition or disease that requires prolonged specialized medical care. The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Referrals to out of network specialty care centers

Prior approval is required by NHP.

Permitted for members with a ≥life threatening≤ or ≥degenerative and disabling≤ condition or disease which requires prolonged specialized medical care and if NHP does not have a network specialty care centers of needed type. The PCP or Specialist must contact NHP UM at 1-800-765-3805.

Continuity of care provider left NHP network

Prior approval is required by NHP.

Transition period of up to 90 days if member needs to continue ≥ongoing≤ treatment with current provider. Or, if member is in 2^nd trimester of pregnancy, transition period is through post-partum care related to delivery. Member must call NHP Member Services and request approval. UM reviews all requests and may give approval.

Cosmetic Surgery

Not covered unless based on medical necessity. Prior authorization is required

Continuity of care -

new member with a non-participating provider

Prior approval is required by NHP. Transition period of up to 60 days if member has a ≥life threatening≤ or ≥degenerative and disabling≤ condition or disease. Or, if member is in 2^nd trimester of pregnancy, transition period is through post-partum care related to delivery. Member must call NHP Member Services and request approval. The non-participating provider must contact NHP UM at 1-800-765-3805.

No prior approval is needed from NHP. No notification requirement. Based on diagnosis, either the emergency room rate is paid or a request is made to the hospital to submit the medical record. If the medical record is not received within 45 days, the triage rate is paid.

Note: CHP and FHP members have a 40 visit per calendar year limitation.

Prior approval is required by NHP except for the first visit for evaluation by a Speech Therapist. For continuing speech therapy, the PCP, therapist or authorized referral specialist must call NHP UM at 1-800-765-3805. For physical and occupational therapy only a referral voucher form is required.

UM (Prior Approval)

NHP Provider Services

Magellan Behavioral Health (MBH)

Healthplex

Davis Vision