Is the bill for a copayment? A non-covered service?  If it is, it's up to you to pay for these.  Still can't fiure out why you got a bill? Call Member Services at 413-787-4004 or 800-310-2835, 8 a.m.-5 p.m., Monday-Friday. You also can check out what claims we have paid at HNEDirect. That's just one of the many things you can do on our secure, interactive web page.

No, you do not need a referral from your PCP for specialty care.  Some services do require prior approval.  Log into HNEDirect to see prior approval information specific to your plan.  That's just one of the many things you can do on our secure, interactive web page.

Are you an HMO member?

Most of the time, the services you need will be available with in-plan providers.  If you do need non-emergency services out-of-plan - HNE has to approve them in advance. 

To see an out-of-plan specialist:

• Before scheduling an appointment, ask your PCP or treating doctor to send an Authorization Request form.
• After reviewing the request, we will notify you and your doctor of our decision in writing.

 

Are you a PPO or POS member?

If you are enrolled in a PPO or point of service plan, you can visit any provider. Remember, though, your costs are lower and coverage levels higher when you visit plan providers.

Whenever your doctor sends you to another doctor, make sure he or she is an HNE in-plan provider. Login to HNEDirect and search for doctors who participate in your plan.  That's just one of the many things you can do on our secure, interactive web page.  Or call Member Services at 413-787-4004 or 800-310-2835, 8 a.m.-5 p.m., Monday-Friday.

No. Most plans cover one annual vision exam as long as you visit a plan provider. Some plans cover one exam with in-plan providers every two years.

Our PPO and point of service plans cover services from out-of-plan providers, although your costs are higher and coverage levels lower.

Log into HNEDirect to see information specific to your plan.  That's just one of the many things you can do on our secure, interactive web page.

No, as long as your doctor participates with HNE. We cover medically necessary obstetrical and gynecological services with any plan provider.

Members of point of service and PPO plans may visit any provider,although your costs are higher and coverage levels lower when you see an out-of-plan provider.

Even if you intend to get all of your care from out-of-plan providers, there may be times when you want to receive the in-plan level of coverage. To do this, you must select a PCP from HNE’s provider directory.

• If you need care and want to use a plan provider, the services you receive are still coordinated through your plan PCP, except in an emergency.
• If you want to receive certain specialty care at the in-plan level of coverage, you must get a referral from a plan PCP.

Log in to HNEDirect and search for PCPs who participate in your plan.  Once you find the doctor you want, you can select your new PCP right on line.  Or call Member Services at 413-787-4004 or 800-310-2835, 8 a.m.-5 p.m., Monday-Friday.

If you are enrolled in a fully funded plan:

In general, your dependents are covered until age 21. However, they can be covered until age 26 as long as they are enrolled as full-time students at an accredited school, such as a college, junior college, or trade school or claimed on your income taxes. (Your employer may change the age limit). The student must also meet all other eligibility criteria outlined in your membership materials.

HNE follows a process to verify student dependent status. Here’s how it works:

One month before a dependent turns 21, we send a letter notifying you that once dependents reach that age, they are not covered unless they are full-time students at an accredited school or claimed on your income taxes. We will send you a letter asking you to attest to either their full time student status or that you claim them on your income taxes.

At least annually (depending on your plan), we will send you a letter asking you to complete a form verifying that your child is still enrolled as a full-time student or claimed on your taxes. You do not need to contact the school. As long as you complete and sign the form and return it to HNE, your child will continue to receive benefits until he or she is no longer a full-time student, reaches the plan’s age limit or is no longer claimed on your taxes, whichever comes first.

It is your responsibility to notify us when your child is no longer enrolled on a full-time basis or no longer claimed on your taxes.

All members are covered for emergency care outside our service area, including foreign countries. If your child is seriously ill or injured and needs immediate medical attention, he or she should call 911 or go to the nearest emergency room right away.

If you are enrolled in an HMO or Exclusive plan, please keep in mind:

Call Member Services at 800-310-2835 to notify us of emergency services that are not received in a hospital emergency room (for example, at a walk-in clinic or doctor’s office).

The Primary Care Physician always coordinates follow-up care, which must be performed by plan providers in the service area.

Your children still have access to routine care æ simply schedule PCP visits when they plan on being home.

If you are enrolled in a self funded plan:

Eligibility requirements may very by plan. Log into HNEDirect to see eligibility information specific to your plan.  That's just one of the many things you can do on our secure, interactive web page. 

HNE only covers short-term physical and occupational therapy. For most plans, the benefit is limited to two months or 25 visits, whichever is greater, per condition per calendar year, for each treatment type. Coverage for Group Insurance Commission members is limited to 90 days per acute episode per calendar year. If physical and occupational therapy services are provided as part of a home health care plan, the services are unlimited. However, there must be objective, measurable improvements in your medical or clinical condition during the course of therapy for coverage to continue.

You may have received the test at an out-of-plan facility, which most plans do not cover without HNE’s prior approval. When your doctor sends you for specialty care or tests from another provider, make sure the provider participates with HNE. Login to HNEDirect and search for doctors or facilities who participate in your plan. That's  just one of the many things you can do on our secure, interactive web page. Or call Member Services at 413-787-4004 or 800-310-2835 8 a.m.-5 p.m., Monday-Friday.

No. To obtain coverage for newborn children, you must enroll them within 31 days of the birth. Depending on your plan, you may enroll your child through your employer or HNE. For more information about the enrollment process for your plan, please call Member Services at 413-787-4004 or 800-310-2835, 8 a.m.-5 p.m., Monday-Friday.

All plans include coverage for emergency care outside our service area, including foreign countries. If you’re traveling outside the U.S. and need immediate medical attention, seek treatment right away. Please follow these guidelines:

You are always covered for emergency care.  If you believe you are having a life threatening emergency, call 911 or go to the nearest ER.  

However, the ER is not usually the best place to go for minor injuries or illnesses. Inappropriate ER visits are a key cause of rising health care costs.  ERs are often crowded, and patients are treated based on the severity of their condition. That means you may often have a long wait. Since they don’t know you at the ER, you won’t get the same personalized service that you get from your own doctor. The ER doctor won’t be familiar with your medical history, and may not be aware of conditions for which you are being treated. ERs also cost much more than the services you get from your own doctor – both for you and your health plan. For example, your ER copayment is most likely much higher than your office visit copayment.

HNE requires your doctor’s office to have 24 hour phone coverage. That way, if you need care after hours, you can call the office. Your doctor or someone covering will help you decide what to do – whether you should get care right away or wait to see your own doctor. HNE also has a 24 hour nurse line. If you can’t reach your doctor, call us at 413.787.4000 or toll free 800.842.4464, choose option 2 (member covered by HNE), then option 6 (HNE nurse line). An experienced nurse will listen carefully to your concerns and give you information to help you choose the care that’s right for you.

We cover ambulance services in emergencies or when medically necessary æ for instance, if you need oxygen, cardiopulmonary resuscitation or other life-sustaining services. We cover ambulance transportation to the nearest hospital that can provide the care you need, as well as transfer from one health care facility to another.

Yes, HNE covers flu shots for all members.  HNE does not cover the intranasal flu vaccination. 

We cover bone density tests when performed by radiologists, orthopedists and OB/GYNs who participate in our plans. We do not cover bone density tests by ultrasound.

Contact the Massachusetts Board of Registration in Medicine at 617-727-3086 for a Physicians Profile that can be mailed or faxed. You can get up to 10 profiles per call. Or, visit them at massmedboard.org.

Are you an HMO member?
All non-emergency services with out of-plan providers require prior approval.  In addition, a limited number of in-plan services require prior approval.  Log into HNEDirect to see prior approval information specific to your plan.

Are you a POS or PPO member?
A limited number of services require prior approval.  Log into HNEDirect to see prior approval information specific to your plan. Remember, for those services that require prior approval, if you get services out-of-plan without prior approval, your coverage may be reduced or denied.