Staying on track...

Policies to help you protect your practice and your future.

 

HNS is committed to the delivery of safe, quality, cost-efficient health care.  Further, HNS is committed to the prevention and detection of potential fraud, waste, and abuse in private, federal and state health care programs, and throughout the health care industry, and to compliance to all applicable laws and regulations.

 

HNS policies were developed to help improve access to, and the delivery of,  safe, quality and cost-efficient health care provided by our contracted providers and were developed in accordance with industry standards, federal and state laws and the policies of our contracted managed care organizations.

 

As the first line of defense against risk, adherence to these policies will help you protect your practice and assist you in meeting the high standards established for all health care professionals.

 

HNS reserves the right to periodically review and revise its policies.   While the HNS Practice Protection Plan is updated periodically, it may not reflect the most current policies. 

 

By executing the HNS Practitioner's Participation Agreement, you have agreed to comply with all HNS policies, procedures and program requirements.  However, these policies should not be followed if doing so could adversely affect the delivery of appropriate patient care.

 

The following policies apply to all HNS providers and are applicable to all services provided to members whose healthcare plan contracts with HNSWhile contracted health care professionals must comply with all HNS and payor policies, specific importance is placed on the following core compliance policies.

 

HNS' Core Policies 

  • All contracted health care providers must ensure the delivery of safe, quality, cost-efficient care to all patients. 
  • All services billed through HNS must be consistent with HNS policies, HNS Payor Policies, the practice guides issued by the state licensing board in the state in which the provider practices and all state and federal statutes and regulations.
  • All services billed through HNS must be medically necessary, consistent with the documented chief complaint, clinical findings, diagnoses and treatment plan. (Exception: maintenance/supportive care when offered as a covered service.)
  • Clinical examination findings must objectively substantiate the medical necessity of services provided and billed through HNS.
  • All services must be properly documented and properly coded with the most accurate CPT codes (and appropriate modifiers, if applicable) and the most accurate HCPCS and diagnosis codes.
  • Contracted providers must not waive or reduce member co-payments, deductibles and/or co-insurance.
  • Claims for all covered services provided must be filed through HNS. This includes claims for secondary coverage if the payor contracts with HNS. 

 

Important Note:  Unless the patient specifically requests that the provider not file his/her claims to the health care plan, the provider must file the claims to HNS, as required by HNS Policy.  If the patient specifically request the provider not file claims, the provider may ONLY comply with this request, provided the patient (or legal guardian) has signed and dated one of the HNS Election Not to File forms, and the form is maintained in the patient's health care record, and is available for review, upon request, by HNS or by a representative of the applicable health care plan. 

 

Compliance to HNS and HNS contracted payor policies and the terms of the HNS Practitioner's Participation Agreement is required for continued participation in the HNS network.

HNS providers must comply with all HNS contracted payor policies and the requirements and policies referenced or included in the HNS Practitioner's Participation Agreement, and/or referenced or included in this website, provided they do not conflict with any state or federal requirements. These policies should not be followed if doing so could adversely affect the delivery of patient care.

Should a violation occur or should HNS or a HNS contracted payor suspect a policy violation, HNS may take one or more of the following actions:

  1. Require the provider to submit a signed attestation statement indicating he/she has read, understands and agrees to comply with HNS and HNS Payor Policies.
  2. Require the submission of a written corrective action plan.
  3. Require the submission of copies of patient healthcare and financial records for review.
  4. Require the provider to obtain additional continuing education.
  5. Place the provider on Probationary Status.
  6. Terminate the Provider's Practitioner's Participation Agreement.
  7. Other such actions as deemed appropriate by the HNS Continuous Quality Improvement (CQI) Committee.

  

Professional Ethics

Network providers must abide by all policies and procedures of HNS as consistent with moral, ethical and professional standards of behavior. Providers must agree to adhere to generally recognized standards of medical and professional ethics.


HNS Contracted Payor Policies

All network providers must adhere to all policies established by the insurers and PPO's that contract with HNS.


HNS Credentialing Policies

The responsibility of credentialing network providers has been delegated to HNS; HNS seeks to credential and recredential providers in accordance to NCQA and other nationally recognized credentialing authorities.  HNS network providers must comply with all HNS credentialing policies.

 

 

Board of Examiner
Rules / Regulations / Practice Guides

All providers in the HNS network must comply with the rules, regulations and Practice Guides issued by their respective state boards.

Please be sure to review all information provided by your state licensing board, including practice guides, information regarding standard of care and scope of practice as well as all other rules and regulations established by your state licensing board. 

 

HNS policies and most payor corporate medical policies are listed on the left side of this page.  Please click on the appropriate heading to review the policy.