HNE Utilizes Physician Reviewers

HNE uses Physician Reviewers (PR) as advisors and/or consultants to provide clinical input specific to determination of medical necessity and appropriateness of selected services or member cases. The PR acts as a resource and designee of the Plan Medical Director. Furthermore, a physician PR, Associate Medical Director and/or Medical Directoris the final decision-maker for any denial based on medical necessity or appropriateness.

HNE has a process for accessing board-certified specialty physicians to assist in making utilization management determinations. A PR is accessed for either an inpatient or outpatient service determination. An Inpatient PR is an HNE physician with privileges at one or more local, participating hospitals. An Outpatient PR is affiliated with HNE and/or Harvard Pilgrim Health Care (HPHC) and is utilized to review services within a specialty area in which he/she practices and is board certified.

When a requesting physician receives a denial determination and has additional information that may influence that denial decision, the physician can call the HNE Nurse Reviewer listed on the denial letter. A HNE Physician Reviewer is also available to the requesting physician to discuss denial decisions. The requesting physician can contact the HNE Physician Reviewer by calling the HSM Department. The HSM Secretary will receive the call, obtain the relevant plan information for the case and connect the requesting physician to a HNE Physician Reviewer. The HSM Department can be reached at 413-787-4000, ext. 3458.