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

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

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

      1. a. Crisis intervention;
      2. b. Detoxification; or
      3. c. Medical or somatic treatment;
   2. (2) Alcohol or drug assessment;
   3. (3) Alcohol or drug case management;
   4. (4) Alcohol or drug services group counseling by clinician;
   5. (5) Alcohol or drug intensive outpatient treatment;
   6. (6) Alcohol or drug methadone or equivalent administration;
   7. (7) Alcohol or drug subacute detox;
   8. (8) Alcohol or drug treatment medication training and support;
   9. (9) Ambulance;
   10. (10) Behavioral health (BH) or Substance use disorder (SUD) comprehensive community support services;
   11. (11) BH or SUD comprehensive medication services;
   12. (12) Behavioral health counseling and therapy, or screening to determine eligibility for admission to a treatment program;
   13. (13) Behavioral health partial hospitalization;
   14. (14) Behavioral health short term residential;
   15. (15) Chiropractic;
   16. (16) Contraceptive services;
   17. (17) Dental diagnostic services;
   18. (18) Dental preventive services;
   19. (19) Dental restorative services;
   20. (20) Diagnostic physical therapy (PT) evaluation;
   21. (21) Individual or group counseling for mental health (MH) or SUD;
   22. (22) Mammogram;
   23. (23) PT procedures not requiring specialized equipment;
   24. (24) Preventive and associated routine care, adult;
   25. (25) Preventive and associated routine care, pediatric;
   26. (26) Routine electrocardiogram (EKG);
   27. (27) Routine immunizations and injections, adult;
   28. (28) Routine immunizations and injections, pediatric;
   29. (29) Screening and assessment services for MH or SUD;
   30. (30) Suture of non-life-threatening wound;
   31. (31) Therapeutic behavioral services provided in segments defined by number of minutes or on a per diem basis;
   32. (32) Urgent care; and
   33. (33) Venipuncture or collection of capillary blood.

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

   1. (1) Allergen immunotherapy;
   2. (2) Ankle X-ray;
   3. (3) Appling splints;
   4. (4) Asthma or bronchial care;
   5. (5) Audiologic function tests;
   6. (6) Biopsy of skin lesions;
   7. (7) Cardiac monitoring or stress testing;
   8. (8) Cardioversion;
   9. (9) Cataract surgery;
   10. (10) Chemotherapy;
   11. (11) Chest X-ray;
   12. (12) Complex closure of wounds;
   13. (13) Corpus uteri biopsy or endometrial sampling;
   14. (14) Cystoscopy;
   15. (15) Dental adjunctive general services;
   16. (16) Dental endodontics;
   17. (17) Dental implant service;
   18. (18) Dental oral and maxillofacial surgery;
   19. (19) Dental orthodontics;
   20. (20) Dental periodontics;
   21. (21) Dental prosthodontics which are removable;
   22. (22) Destruction of skin lesions;
   23. (23) Developmental, hearing, and vision testing, pediatric;
   24. (24) Diagnosis and therapy for rheumatic disease;
   25. (25) Electroencephalography (EEG);
   26. (26) Echocardiography;
   27. (27) Electromyography;
   28. (28) Endoscopy;
   29. (29) Excision of lesions, benign;
   30. (30) Eye care medical treatment;
   31. (31) Eye exam;
   32. (32) Gastrointestinal endoscopy;
   33. (33) General psychiatric care on an inpatient basis;
   34. (34) Incision and drainage, deep abscess;
   35. (35) Injection of eye drug;
   36. (36) Injection of spine;
   37. (37) Injection of tendon or joint;
   38. (38) Insertion or removal of intrauterine contraceptive device;
   39. (39) Knee arthroscopy;
   40. (40) Laparoscopic surgery;
   41. (41) Laryngoscopy;
   42. (42) Nasal endoscopy;
   43. (43) Non-routine venipuncture;
   44. (44) Occupational therapy;
   45. (45) Osteopathic manipulation;
   46. (46) Paring or cutting benign lesion;
   47. (47) Partial mastectomy;
   48. (48) Peripherally inserted central catheter (PICC);
   49. (49) Psychiatric diagnostic evaluation with medical services;
   50. (50) Renal dialysis;
   51. (51) Routine endoscopy;
   52. (52) Routine pre-natal care;
   53. (53) Skin graft;
   54. (54) Speech therapy;
   55. (55) Spinal injection or nerve block;
   56. (56) Surgical debridement of nails;
   57. (57) Thoracentesis;
   58. (58) Wax or foreign body removal from ear;
   59. (59) Wound debridement; and
   60. (61) X-ray absorptiometry or bone density study.

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

   1. (1) Alcohol or drug acute detox;
   2. (2) Allergy testing;
   3. (3) Amputation of toe or foot;
   4. (4) Arthrodesis;
   5. (5) Biopsy or excision of lymph nodes;
   6. (6) Bone biopsy or procedure to obtain tissue;
   7. (7) Breast repair or reconstruction;
   8. (8) Bronchoscopy;
   9. (9) Cardiac catheterization;
   10. (10) Complete mastectomy;
   11. (11) Complex endoscopy;
   12. (12) Dental prosthodontics which are fixed;
   13. (13) Draw blood off cardiovascular venous device;
   14. (14) Emergency endotracheal intubation;
   15. (15) Excision of lesions, malignant;
   16. (16) Hysterectomy;
   17. (17) Incision and drainage, skin or wound;
   18. (18) Insertion of central venous catheter;
   19. (19) Low back disk surgery;
   20. (20) Magnetic resonance imaging (MRI) of lower extremity;
   21. (21) Radiation therapy;
   22. (22) Radiation treatment;
   23. (23) Radiation treatment management;
   24. (24) Repair of shoulder joint;
   25. (25) Replacement of aortic valve;
   26. (26) Routine obstetrical care with vaginal delivery;
   27. (27) Spinal bone autograft or allograft;
   28. (28) Spinal instrumentation;
   29. (29) Surgical laparoscopy;
   30. (30) Surgical vascular endoscopy;
   31. (31) Tibia fracture treatment;
   32. (32) Total hip replacement;
   33. (33) Total knee replacement; and
   34. (34) Treatment of ankle fracture.
5. (e) All other covered services shall be available from providers within New England.
6. (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.

Source. #7701, eff 8-1-02; ss by #9399, eff 3-1-09; ss by #9722, eff 8-1-10 (from Ins 2701.05); ss by #12565, eff 8-1-18