N.H. Admin. Code He, He-W, ch. He-W 500, app A
Rule | Title | Publisher; How to Obtain; and Cost |
He-W 511.05 | Chapter 3, Section 3910, Medicaid Payments for Recipients under Group Health Plans, of the federal Centers for Medicare and Medicaid Services (CMS), State Medicaid Manual | Publisher: Centers for Medicare and Medicaid Services (CMS). This document is available for free on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html |
He-W 513.02(b)(2), (p) (3); 513.04(f); 513.05(b)(1), (h)-(l), (m)(3)-(4), (n) intro, (n)(6), (o) intro, (u)(3)e.; and 513.06(a) | ASAM Criteria: Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, 3rd edition (2013) | Publisher: American Society of Addiction Medicine (ASAM). The ASAM Criteria (2013) can be purchased online through the ASAM website at: http://www.asamcriteria.org/. Cost = $95 (non-members) or $85 (members). Discounts are available for large purchases. |
He-W 513.02(b)(3), (q) (3); 513.04(g); 513.05(b)(1), (h)intro.-(l)intro, (n) intro, (n)(5), (o) intro, (u)(2)e.; 513.06(a), and 513.11 | ASAM Criteria: Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, 3rd edition (2013) | Publisher: American Society of Addiction Medicine (ASAM). The ASAM Criteria (2013) can be purchased online through the ASAM website at: http://www.asamcriteria.org/. Cost = $95 (non-members) or $85 (members). Discounts are available for large purchases. |
He-W 513.02(x), 513.05(l)(1)a. | The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) (DSM-5) | Publisher: The American Psychiatric Association (APA). The DSM-5 can be purchased on line at: http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=2554 Cost = $199 |
He-W 513.02(aa), 513.05(l)(1)a. | The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) (DSM-5) | Publisher: The American Psychiatric Association (APA). The DSM-5 can be purchased on line at: https://www.appi.org/Diagnostic_and_Statistical_Manual_of_Mental_Disorders_DSM-5_Fifth_Edition Cost = $157.50 -$210 depending upon APA affiliation |
He-W 513.02(ad)(1) and He-W 513.05(b)(6) | Addiction Counseling Competencies, TAP 21 (2017 revision) | Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: https://store.samhsa.gov/files/sma12-4171pdf |
He-W 513.02(aa)(1) | Addiction Counseling Competencies, TAP 21 (2011 revision) | Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: http://store.samhsa.gov/shin/content//SMA12-4171/SMA12-4171.pdf |
He-W 513.02(aa), 513.05(l)(1)a. | The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) (DSM-5) | Publisher: The American Psychiatric Association (APA). The DSM-5 can be purchased on line at: https://www.appi.org/Diagnostic_and_Statistical_Manual_of_Mental_Disorders_DSM-5_Fifth_Edition Cost = $157.50 -$210 depending upon APA affiliation |
He-W 513.02(ad)(1) and He-W 513.05(b)(6) | Addiction Counseling Competencies, TAP 21 (2017 revision) | Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: https://store.samhsa.gov/files/sma12-4171pdf |
He-W 513.05(c)(3), 513.05(d)(3) | Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment, TAP 33 (2013 edition) | Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: https://store.samhsa.gov/product/tap-33-systems-level-implementation-screening-brief-intervention-referral-treatment-sbirt |
He-W 513.05(g)(1)b. | TIP 63: Medications for Opioid Use Disorder (2018) | Publisher: The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. The document is included in the Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, Treatment Improvement Protocol (Tips) #40. The document can be accessed online at https://store.samhsa.gov/product/tip-63-medications-opioid-use-disorder-%E2%80%93-full-document-including-executive-summary-parts-1-5 |
He-W 513.05(g)(1)c. | Federation of State Medical Boards - Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office (2004) | Publisher: The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. The document is included in the Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, Treatment Improvement Protocol (Tips) #40. The document can be accessed online at http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf |
He-W 521.04(c)(1) | For CMS-1500, "Health Insurance Claim Form" (02/12) | Publisher:National Uniform Claim Committee. This form can be obtained by one of the following: * Your current forms supplier; and * https://www.nucc.org/index.php/1500-claim-form-mainmenu-35 or by calling 800-482-9367 ext. 58029 Cost: Varies based upon quantity |
He-W 521.04(c)(2) | Form CMS-1450, "UB-04" (Jan 2023) | Publisher: National Uniform Billing Committee This document can be assessed online by subscribers at: https://www.nubc.org/nubc-resources This document can also be obtained online at: https://highered.mheducation.com/sites/dl/free/0073520896/836077/UB04_jan23.pdf Cost: Varies based upon quantity |
He-W 521.04(c)(3) | ADA American Dental Association Dental Claim Form (2024) | Publisher: ADA American Dental Association This document can be assessed online at the American Dental Association website at https://store.ada.org/catalog/dental-claim-form-2024-version-downloadable-pdf-123970 Cost: Varies based upon quantity |
He-W 530.05(b)(4) | Medicare Coverage Database | Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the "Medicare Coverage Database" at http://www.cms.gov/medicare-coverage-database/ (under the "Quick Search" function, select "National Coverage Documents", optionally enter a filter by entering a "keyword" to narrow the search results, and select the "Search by Type" button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein. |
He-W 530.05(b)(32)a. | Medicare Coverage Database | Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the "Medicare Coverage Database" at http://www.cms.gov/medicare-coverage-database/ (under the "Quick Search" function, select "National Coverage Documents", optionally enter a filter by entering a "keyword" to narrow the search results, and select the "Search by Type" button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein. |
He-W 530.05(b)(32)b.1. | Anthem Medical Policies and Clinical UM Guidelines | Publisher: Anthem Insurance Companies Anthem Medical Policies and Clinical UM Guidelines can be obtained from: http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/wi/f5/s1/t4/pw_ad080065.htm&state=wi&rootLevel=0&label=Anthem%20Medical%20Policies (select the "Continue" button to confirm that the page has been read and proceed to the "Overview" page, then select the "Click Here to Search" button in the middle of this page to continue to the search engine, enter search criteria for the specific coverage policy, and then select the specific coverage policy). There is no cost to access the website or print the material contained therein. |
He-W 530.05(b)(32)b.2. | Cigna Coverage Policies | Publisher: Cigna Insurance Company Cigna Coverage Policies can be obtained from https://cignaforhcp.cigna.com (select "RESOURCES" at the top of the page, then select "Coverage Policies", then select "Medical A-Z Index" for an alphabetical list of policies, and then select the specific coverage policy). There is no cost to access the website or print the material contained therein. |
He-W 530.05(b)(32) b.3. | Aetna Clinical Policy Bulletins | Publisher: Aetna Insurance Company Aetna Clinical Policy Bulletins can be obtained from http://www.aetna.com/healthcare-professionals/policies-guidelines/cpb_alpha.html (select specific bulletin from the alphabetical listing of clinical policy bulletins). There is no cost to access the website or print the material contained therein. |
He-W 530.07(g)(9) | Milliman Clinical Guidelines, 17th Edition (February/March 2013) | Publisher: MCG Health, LLC. 901 Fifth Avenue, Suite 2000, Seattle, WA 98164. Phone: 206-389-5300; Toll-Free: 888-464-4746. Fax: 206-464-7813. http://www.careguidelines.com/. Cost per guideline: approximately $6,000. NH Medicaid providers and recipients may obtain relevant portions of the guidelines (e.g., the specific criteria related to a prior authorization denial) free of charge and upon request by contacting the Department's Prior Authorization Agent, KeyPro, at 2810 N. Parham Rd., Suite 305, Henrico, VA 23294 PHONE: (800) 299-5921 FAX: (800) 922-9847. |
He-W 531.05(b)-(g) | Interqual Connect Clinical Guidelines, 2019 Edition | Publisher: Change Healthcare (McKesson), 3055 Lebanon Pike, Nashville, TN 37214. Phone:615-932-3000; Toll-Free: 1-800-274-8374. Fax: 615-231-4843. interqualsupport@changehealthcare.com Cost $367,475 NH Medicaid providers and recipients may obtain relevant portions of the guidelines (e.g., the specific criteria related to a prior authorization denial) free of charge and upon request by contacting their managed care organization: AmeriHealth Caritas https://www.amerihealthcaritasnh.com/ Member Services: 1-833-704-1177 (TTY: 1-855-534-6730) New Hampshire Healthy Families, http://www.nhhealthyfamilies.com/ Member Services: 1-866-769-3085 (TTY/TDD: 1-855-742-0123) Well Sense Health Plan, http://www.wellsense.org/ Member Services: 1-877-957-1300 (TTY/TDD: 711) |
He-W 531.06(e) | Medicare Coverage Database | Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the "Medicare Coverage Database" at http://www.cms.gov/medicare-coverage-database/ (under the "Quick Search" function, select "National Coverage Documents", optionally enter a filter by entering a "keyword" to narrow the search results, and select the "Search by Type" button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein. |
He-W 546.05(a)(1) intro. | Recommendations for Preventive Pediatric Health Care (2014) | Publisher: American Academy of Pediatrics/Bright Futures. Available free of charge at: http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf |
He-W 546.05(a)(1)j. | Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (2013 revision) | Publisher: American Academy of Pediatric Dentistry. Available free of charge at: http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf |
He-W 546.05(b)(5) | Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, United States 2015 | Publisher: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available free of charge at: http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf |
He-W 547.04(c)(6)d. | "Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents," 3rd edition, 2008. | Published by the American Academy of Pediatrics. PDFs of each chapter of the guidelines can be downloaded free of charge from: http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html. The complete document can be ordered from the AAP Bookstore at a cost of $64.95 at https://www.nfaap.org/, or by writing to: Bright Futures c/o American Academy of Pediatrics 141 Northwest Point Blvd. Elk Grove, IL 60007 |
He-W 547.04(c)(6)j. | "Clinical Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children", of the American Academy of Pediatric Dentistry, 81 Reference Manual 2004-2005, Originating Committee- Clinical Affairs Committee, Review Council- Council on Clinical Affairs, adopted 1991, Revised, 1992, 1996, 2000, and 2003. | Published by the American Academy of Pediatric Dentistry. Available on-line, at: http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf. Free of charge. |
He-W 568.10(b) | American Medicaid Association's "Current Procedural Terminology (CPT) 2022 Professional Edition" | Publisher: American Medical Association Cost: $109.76 The incorporated document is available for purchase at https://www.amazon.com/stores/page/112D63A3-2DF2-490B-A8CA-79D03F0F0E99 |
He-W 569.06(d)(1) & (d)(2)a.-d. | Milliman Clinical Guidelines, 17th Edition (February/March 2013) | Publisher: MCG Health, LLC. 901 Fifth Avenue, Suite 2000, Seattle, WA 98164. Phone: 206-389-5300; Toll-Free: 888-464-4746. Fax: 206-464-7813. http://www.careguidelines.com/. Cost per guideline: approximately $6,000. NH Medicaid providers and recipients may obtain relevant portions of the guidelines (e.g., the specific criteria related to a prior authorization denial) free of charge and upon request by contacting the Department's Prior Authorization Agent (currently KePro) at 1-800-299-5921. |
He-W 571.04(c)(21) | Medicare Coverage Database | Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the "Medicare Coverage Database" at http://www.cms.gov/medicare-coverage-database/ (under the "Quick Search" function, select "National Coverage Documents", optionally enter a filter by entering a "keyword" to narrow the search results, and select the "Search by Type" button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein. |
N.H. Admin. Code He, He-W, ch. He-W 500, app A