N.H. Admin. Code He, He-W, ch. He-W 500, app A

Current through Register No. 36, September 5, 2024

Appendix A - Incorporation by Reference Information

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, 3^rd 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) (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 513.05(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: http://store.samhsa.gov/shin/content//SMA13-4741/TAP33.pdf
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 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-W531.05(b) -(g)	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 531.06(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-W547.04(c) (6) d.	"Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents," 3^rd 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 Futuresc/o American Academy of Pediatrics141 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 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.

He-W 530.05(b) (4)