Helpful Information Quality Management Programs
At HNE, we're committed to making sure that you get the best possible care and service. So how do we do that? There are a lot of different ways - and they all fall under our Quality Management Program. Each year, HNE develops a Quality Management Work Plan that lists the activities that we do each year. For a copy of the latest one and more information on these programs, call HNE Member Services.
Utilization Management
Health New England Medicare Advantage conducts utilization review of the medical care (Medicare Part C) and prescription drugs (Medicare Part D) you receive under our Plan. The goal of utilization management is to ensure that the care that our members receive is medically necessary. These requirements and limits ensure that our members use their medical and prescription benefits in the most effective way and also help us control plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our plan to help us provide quality coverage to our members. Health New England Medicare Advantage reviews medical necessity in three ways which includes prior authorization, concurrent review and retrospective review.
For a list of medical care, services, supplies and equipment that require "prior authorization" refer to the Benefit Chart in your Evidence of Coverage. For members with prescription drug coverage (Medicare Part D), we have additional requirements for coverage. These requirements can be found at Prior Authorization, Step Therapy and Quantity Limit.
Medication Therapy Management (MTM) Program
If you have complex health needs, you may be eligible to participate in our MTM Program. HNE, in collaboration with our Pharmacy Benefit Manager, National Pharmaceutical Services (NPS), offers a MTM Program at no additional cost. Our MTM Program is free and includes a discussion and review of all your medications by a pharmacist or other health professional.
HNE Medicare Advantage Clinical Programs
HNE offers various Clinical Programs designed to help our members when they need it the most during a period of illness or while managing a chronic condition. Some of our programs are designed to save our members money, while others specialize in keeping members out of the hospital.
Re-admission Prevention/Transition Management Program
HNE Medicare Advantage offers a 30-day transition program to support members who have a high risk of readmission following discharge from a hospital or skilled nursing facility.
H8578_2016_049 Approved
The information on this page was last updated on 2/18/2016