(a) The purpose of this section is to classify services into 3 categories, core, common, and specialized, for the purposes of network adequacy reviews.

(b) The following services shall be classified as “Core” services for purposes of network adequacy review:

(1) Alcohol or drug treatment in an ambulatory setting for any of the following:

a. Crisis intervention;

b. Detoxification; or

c. Medical or somatic treatment;

(2) Alcohol or drug assessment;

(3) Alcohol or drug case management;

(4) Alcohol or drug services group counseling by clinician;

(5) Alcohol or drug intensive outpatient treatment;

(6) Alcohol or drug methadone or equivalent administration;

(7) Alcohol or drug subacute detox;

(8) Alcohol or drug treatment medication training and support;

(9) Ambulance;

(10) Behavioral health (BH) or Substance use disorder (SUD) comprehensive community support services;

(11) BH or SUD comprehensive medication services;

(12) Behavioral health counseling and therapy, or screening to determine eligibility for admission to a treatment program;

(13) Behavioral health partial hospitalization;

(14) Behavioral health short term residential;

(15) Chiropractic;

(16) Contraceptive services;

(17) Dental diagnostic services;

(18) Dental preventive services;

(19) Dental restorative services;

(20) Diagnostic physical therapy (PT) evaluation;

(21) Individual or group counseling for mental health (MH) or SUD;

(22) Mammogram;

(23) PT procedures not requiring specialized equipment;

(24) Preventive and associated routine care, adult;

(25) Preventive and associated routine care, pediatric;

(26) Routine electrocardiogram (EKG);

(27) Routine immunizations and injections, adult;

(28) Routine immunizations and injections, pediatric;

(29) Screening and assessment services for MH or SUD;

(30) Suture of non-life-threatening wound;

(31) Therapeutic behavioral services provided in segments defined by number of minutes or on a per diem basis;

(32) Urgent care; and

(33) Venipuncture or collection of capillary blood.

(c) The following services shall be classified as “Common” services for purposes of network adequacy review:

(1) Allergen immunotherapy;

(2) Ankle X-ray;

(3) Appling splints;

(4) Asthma or bronchial care;

(5) Audiologic function tests;

(6) Biopsy of skin lesions;

(7) Cardiac monitoring or stress testing;

(8) Cardioversion;

(9) Cataract surgery;

(10) Chemotherapy;

(11) Chest X-ray;

(12) Complex closure of wounds;

(13) Corpus uteri biopsy or endometrial sampling;

(14) Cystoscopy;

(15) Dental adjunctive general services;

(16) Dental endodontics;

(17) Dental implant service;

(18) Dental oral and maxillofacial surgery;

(19) Dental orthodontics;

(20) Dental periodontics;

(21) Dental prosthodontics which are removable;

(22) Destruction of skin lesions;

(23) Developmental, hearing, and vision testing, pediatric;

(24) Diagnosis and therapy for rheumatic disease;

(25) Electroencephalography (EEG);

(26) Echocardiography;

(27) Electromyography;

(28) Endoscopy;

(29) Excision of lesions, benign;

(30) Eye care medical treatment;

(31) Eye exam;

(32) Gastrointestinal endoscopy;

(33) General psychiatric care on an inpatient basis;

(34) Incision and drainage, deep abscess;

(35) Injection of eye drug;

(36) Injection of spine;

(37) Injection of tendon or joint;

(38) Insertion or removal of intrauterine contraceptive device;

(39) Knee arthroscopy;

(40) Laparoscopic surgery;

(41) Laryngoscopy;

(42) Nasal endoscopy;

(43) Non-routine venipuncture;

(44) Occupational therapy;

(45) Osteopathic manipulation;

(46) Paring or cutting benign lesion;

(47) Partial mastectomy;

(48) Peripherally inserted central catheter (PICC);

(49) Psychiatric diagnostic evaluation with medical services;

(50) Renal dialysis;

(51) Routine endoscopy;

(52) Routine pre-natal care;

(53) Skin graft;

(54) Speech therapy;

(55) Spinal injection or nerve block;

(56) Surgical debridement of nails;

(57) Thoracentesis;

(58) Wax or foreign body removal from ear;

(59) Wound debridement; and

(61) X-ray absorptiometry or bone density study.

(d) The following services shall be classified as “Specialized” services for purposes of network adequacy review:

(1) Alcohol or drug acute detox;

(2) Allergy testing;

(3) Amputation of toe or foot;

(4) Arthrodesis;

(5) Biopsy or excision of lymph nodes;

(6) Bone biopsy or procedure to obtain tissue;

(7) Breast repair or reconstruction;

(8) Bronchoscopy;

(9) Cardiac catheterization;

(10) Complete mastectomy;

(11) Complex endoscopy;

(12) Dental prosthodontics which are fixed;

(13) Draw blood off cardiovascular venous device;

(14) Emergency endotracheal intubation;

(15) Excision of lesions, malignant;

(16) Hysterectomy;

(17) Incision and drainage, skin or wound;

(18) Insertion of central venous catheter;

(19) Low back disk surgery;

(20) Magnetic resonance imaging (MRI) of lower extremity;

(21) Radiation therapy;

(22) Radiation treatment;

(23) Radiation treatment management;

(24) Repair of shoulder joint;

(25) Replacement of aortic valve;

(26) Routine obstetrical care with vaginal delivery;

(27) Spinal bone autograft or allograft;

(28) Spinal instrumentation;

(29) Surgical laparoscopy;

(30) Surgical vascular endoscopy;

(31) Tibia fracture treatment;

(32) Total hip replacement;

(33) Total knee replacement; and

(34) Treatment of ankle fracture.

(e) All other covered services shall be available from providers within New England.

(f) Prescription medications from a retail pharmacy shall be available within the time and distance standards equal to those associated with the “Core” services for a specific county.

See https://www.gencourt.state.nh.us/rules/state_agencies/ins2700.html