NEW HAMPSHIRE MEDICAID
The State of New Hampshire has contracted Masspro to perform retrospective utilization reviews on selected Medicaid in-state, border and specialty hospital inpatient claims. The scope of this contract includes medical necessity determinations, quality of care assessments and validation of DRG diagnosis and coding.
UTILIZATION MANAGEMENT PROGRAM
Masspro consistently applies the most up-to-date standards of care and uses its structured Utilization Management Program (UMP) review process model to both assess the delivery of healthcare services and to identify opportunities for process improvement and provider education needs. Our UMP process model is based on peer review.
The initial level of review is performed by nurse reviewers using screening criteria, currently InterQual®. Those cases requiring further review are referred to actively practicing, board certified New Hampshire licensed physicians in the same or similar clinical discipline as the care under review. Physician reviewers use their medical judgement, current standards of care and regulatory requirements to render a decision on a case. Only physician reviewers can deny services based on medical necessity and appropriateness of setting.
Masspro notifies the provider of the review determination. If a case is not approved by physician review, the provider has the right to appeal the denial and request a second review by Masspro. The re-review will be performed by a second physician reviewer different from the one who performed the initial review. All denial notices will include a medical rationale along with any appeal rights and, if appropriate, instructions for rebilling.
Should you have any questions or concerns, please contact us at:
Mail: |
Masspro |
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Attn: NH Medicaid Review Manager |
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245 Winter Street |
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Waltham, MA 02451 |
Toll Free Phone: |
888-895-5996 |
Toll Free Fax: |
888-895-5845 |
Email: |
nhm@masspro.org |
NOTE: Templates for NH Medicaid Notices of Non-Coverage are located under Forms in the Tools/Publications tab above.
Consumer Feedback
If you have a comment, complaint, compliment or request for Masspro, please complete a Consumer Feedback Form or dial the operator at 781-890-0011 during normal business hours (8:00 am-5:00 pm, Monday-Friday).
For medical emergencies, please dial 911.
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