New Hampshire NH

New Hampshire expresses PA through PROVIDER BILLING MANUALS published as PDFs on the NH MMIS Health Enterprise Portal (nhmmis.nh.gov), NOT via a dedicated PA code list or standalone PA criteria site. Volume I = General Billing Manual (cross-cutting rules incl. PA process, service-limit overrides, Form 272a denial, 30-day appeal window, third-party PA). Volume II = ~30 per-provider-type / per-specialty manuals (Radiological, Medical Services Clinic, Hospital, Community Mental Health, SUD, Vision, Therapies, DME/Home Infusion, etc.), each carrying its own service-specific PA / medical-necessity requirements. He-W administrative rules are the legal backbone the manuals reference. AUTHORITY: NH DHHS is the agency; canonical published source is the NH MMIS portal operated by the fiscal agent (Conduent/Gainwell lineage). MANAGED CARE: NH Medicaid Care Management = 3 MCOs (AmeriHealth Caritas NH, WellSense/BMC HealthNet, NH Healthy Families/Centene) for medical PA; pharmacy per-MCO PBM (carve-in); FFS PA via manuals + portal. BOT-WALL: dhhs.nh.gov hard-blocks bots (Access Denied even headless). nhmmis.nh.gov is open (200) and serves manuals via /portals/wps/wcm/connect/<uuid>/<name>.pdf. DEAD PIN: state_meta provider_manual www.medicaid.nh.gov/providers/medicaid-provider-manuals.htm now returns NAME_NOT_RESOLVED. Live replacement: nhmmis.nh.gov/portals/wps/portal/ProviderManuals (200).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2024-01-10. Next due: 2029-08-31. Contracts extended through: None.

# NH — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 6 docs. See [[state_shape_NH]]. Correction pass: WISeR is not applicable to NH — WISeR ("Wasteful and Inappropriate Service Reduction") is a CMS Medicare PA model limited to AZ/NJ/OH/OK/TX/WA; NH does not participate. The model's "WISeR pilot status unknown" line was a template artifact, corrected below. The claim that NH "submitted a CMS-0057-F report" is not supported by the source documents and is softened below. ## 1. How NH requires PA New Hampshire's Medicaid program mandates Managed Care Organization (MCO) enrollment for medical, behavioral health (BH), and pharmacy services, with carve-ins to the MCO for certain services like foster care and adult dental. The state employs a provider-specific billing manual approach to outline prior authorization (PA) requirements rather than using a centralized PA code list or standalone criteria site. For example, methadone clinics require step-therapy documentation for authorization per the Medical Services Clinic Manual (Provider Manual II), effective April 2025. Durable medical equipment (DME) requires clinical necessity documentation without step therapy per the General Billing Volume I manual, effective January 1, 2026 (the specific CPT codes cited in source summaries are unverified). Radiological services require documentation of medical necessity but not step therapy per the Radiological Services Provider Manual II, effective February 25, 2025. Psychotropic medications under the Community Mental Health Provider Manual II require prior authorization and threshold criteria (e.g., failure of first-line treatment) without step therapy, effective August 2025. ## 2. How NH publishes and reports PA NH publishes its PA requirements through provider-specific billing manuals on the New Hampshire Medicaid Management Information System (MMIS) portal, accessible via nhmmis.nh.gov. These manuals are categorized into volumes, with Volume I covering general billing rules including PA processes and service-limit overrides. The state does not maintain a dedicated PA code list or standalone site for PA criteria, instead relying on detailed provider manuals. Reporting mechanisms are likely embedded within the MMIS system, though specific reporting channels and frequency are not detailed in the sources. ## 3. NH's CMS-0057-F and PA-reform compliance posture The source documents do not establish NH's exact CMS-0057-F submission status. The Granite Advantage Health Care Program 1115 waiver and the Substance Use Disorder Treatment and Recovery Access (SUD-TRA) 1115 waiver highlight NH's specialized service programs, which may influence its PA policies. The fiscal agent transition from ACS-Inc to Conduent/Gainwell indicates a shift in claims/payment processing infrastructure. Per source documents, the last MCO procurement cycle ended January 10, 2024, with contracts extending through an unspecified date. (WISeR not applicable — NH is not one of the six WISeR-model states.) ## 4. How NH runs its own program New Hampshire's Medicaid program operates under a mandatory MCO enrollment model for medical, behavioral health, and pharmacy services, with carve-ins to MCOs for certain specialized services like foster care and adult dental. The fiscal agent history shows transitions from ACS-Inc to Conduent/Gainwell. The Granite Advantage Health Care Program 1115 waiver and SUD-TRA 1115 waiver are key initiatives shaping NH's Medicaid landscape and likely influence PA policies for specialized services such as substance use disorder treatment. The state's provider-specific billing manuals serve as the primary source of PA requirements. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Provider-Specific Manuals:** NH uses provider-specific billing manuals to outline PA requirements rather than a centralized code list. - **Specialized Waivers:** Granite Advantage and SUD-TRA 1115 waivers likely influence specialized-service PA policies. - **Fiscal Agent Transitions:** ACS-Inc → Conduent/Gainwell indicates changes in claims processing. ### What's Missing/Uncertain: - **Specific PA Codes:** No dedicated PA code list or standalone criteria site. - **Reporting Mechanisms:** Exact reporting channels and frequency not detailed. - **Foster Care Program Details:** Unspecified. - **WISeR:** Not applicable — NH is not a WISeR-model state. - **Hospital PA Criteria:** The Hospital Provider Billing Manual does not specify inpatient hospital PA criteria.