HNS Policy 

HNS is committed to the delivery of safe, quality, cost-efficient health care to members of the health care plans we represent.

HNS policies were developed by our CQI Committee in conjunction with our managed care partners to assist you in improving quality of care and patient safety, cost-efficiency, and in meeting the high standards in documentation, coding and compliance established for all health care professionals.

HNS reserves the right to periodically review and revise its policies. While most policies are included in the HNS Practice Protection Plan (Provider Manual), the manual may not include the most current policies.

By executing the HNS Practitioner's Participation Agreement, each health care professional agrees to comply with all HNS policies and the policies of the health plans and managed care organizations which contract with HNS. 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 health care plan contracts with HNS. While 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 performed and billed through HNS must be consistent with HNS Clinical Quality & Documentation Standards, 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, diagnosis and treatment plan. (Exception: when maintenance/supportive care is covered by the payor.)
  
  

• 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.

(Providers should never initiate a conversation with a patient about not filing claims to their health care plan. Providers may only comply with a request not to file if, and only if, the patient has initiated the request, and the policies below are followed.)

Exception: If a patient specifically requests that the provider not file claims to their health care plan, providers may ONLY comply with such requests provided the applicable "HNS Election Not to File Form" is signed and dated by the member, or legal guardian, and is maintained in the health care record, and by available for review by HNS, or by the patient's healthcare plan representative.

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

Should a violation occur or should HNS or a HNS contracted payor suspect a policy violation, HNS may take 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.
   
   

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

HNS is an intermediary between the contracted payors and the providers in our network. As such, our network providers must adhere to all policies established by the insurers and PPO's that you represent as a participating provider.

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. 

Most HNS policies and payor corporate medical policies are listed in the dark red menu bar on the left side of this page. Please click on the appropriate heading to review the policy.