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Prior Authorization Criteria
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Prior Authorizations

Harvard Pilgrim requires prior authorization for specific items and services under most Harvard Pilgrim plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

All requests for prior authorization are processed and a determination is rendered and communicated within two business days of receipt of all necessary information. If additional information is required, you and your provider will be notified in writing regarding the specific information needed within one business day of receipt of the request. Your provider will also be notified by phone prior to the written communication being sent.

If you have an HMO, PPO or POS plan and see an in-network provider (doctor or clinician) within your plan’s network, the provider is responsible for obtaining authorization/prior approval for select services noted below. If you have a PPO or POS product and your provider is out-of-network for your plan, you OR your provider are responsible for obtaining authorization/prior approval. To obtain Authorization/Prior Approval you or your provider should call 1-800-708-4414.

In-network (contracted) providers are responsible for obtaining prior authorization from the plan. In the event they fail to do so, the provider is held responsible for any incurred charges with no financial liability to you, the member.

For certain services, prior authorization review is delegated to contracted vendors. (Harvard Pilgrim retains oversight and overall accountability for all delegated services.) See the criteria used to review prior authorization requests.

  • Behavioral Health services: Prior authorization is delegated to United Behavioral Health (UBH).
  • Prior Outpatient Diagnostic Imaging Services: Prior authorization is delegated to National Imaging Associates (NIA).
    • Effective 7/1/14, prior authorization is required for Interventional Pain Management for Back Pain and Lumbar Spine Surgeries. Prior authorization for these services is also delegated to NIA.
  • Sleep Diagnostics and Sleep Therapy Management: Prior Authorization is delegated to CareCore National (CCN.)

Under most Harvard Pilgrim plans, prior authorization is required for:

  • Admissions to Skilled Nursing Facilities and Inpatient Rehabilitation Hospitals
  • Bariatric Surgeries
  • Behavioral Health services including:
    • Non-emergent inpatient admissions
    • Alternatives to mental health and substance abuse hospitalization (i.e., Day treatment, Intensive outpatient treatment, Partial hospitalization)
    • Non-routine outpatient services including Applied Behavioral Analysis (ABA) for the treatment of autism (may not be covered under certain self-insured plans), and Transcranial Magnetic Stimulation.
  • Breast Reduction and Reconstruction Surgeries
  • Cholecystectomy
  • Continuous Glucose Monitoring Systems
  • Cosmetic/Reconstructive Surgery including:
    • Blepharoplasty
    • Destruction of Vascular Cutaneous Lesions
    • Excision/Surgical Planing of Rhinophyma
    • Panniculectomy/Removal of Excess Tissue
    • Ptosis repair
    • Removal of Breast Implants
    • Repair of Congenital Chest Wall Deformities
    • Rhinoplasty
    • Scar revision
    • Septoplasty
  • Dental and Oral Surgery Services performed in inpatient or SDC settings
  • Formulas and Enteral Nutrition
  • Gender Reassignment Surgeries
  • Genetic Testing for Hereditary Breast and/or Ovarian Cancer
  • Gynecomastia Surgery
  • Hip Arthroplasty/Hip Replacement
  • Home Health Care (e.g., Visiting Nurse, Home Infusion)
  • Hospice Services
  • Hysterectomy
  • Immune Globulin (IVIg)
  • Implantable Neurostimulators
  • Infertility Services including:
    • Collection, storage and cryopreservation (freezing) of eggs, sperm, or embryos
    • Donor oocyte
    • Donor sperm
    • Gamete intra-fallopian transfer (GIFT)
    • Intra-cytoplasmic sperm injection (ICSI)
    • Intra-Uterine Insemination (IUI)
    • In-vitro fertilization (IVF)
    • Embryo Transfer and Frozen embryo transfer (FET)
    • Microsurgical Epididymal Sperm Aspiration (MESA)
    • Testicular Sperm Extraction (TESE)
    • Zygote intra-fallopian transfer (ZIFT)
  • Interventional Pain Management for Back Pain including:
    • Epidural Injections
    • Facet Joint Injections
    • Facet Neurolysis
  • Intravenous Antibiotics for Treatment of Lyme Disease
  • Knee Arthroscopy
  • Knee Arthroplasty/Knee Replacement
  • Non-Emergent Air Ambulance Transportation
  • Outpatient Diagnostic Imaging Services including:
    • Computerized Tomography and Computerized Tomography Angiography (CT/CTA)
    • Magnetic Resonance Imaging and Magnetic Resonance Angiography (MRI/MRA)
    • Nuclear Cardiology
    • Positron Emission Tomography (PET)
    • Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)
    • Outpatient Pulmonary Rehabilitation
  • Outpatient Speech/Language Therapy (MA only)
    • Physical and/or Occupational Therapy services require prior authorization if services are expected to exceed the member’s benefit limit.
  • Prosthetic Devices for Upper and Lower Limbs
  • Pre-Implantation Genetic Testing (PGT)
  • Selected Medical Benefit drugs and biologicals including:
    • Aloxi (palonosetron HCl injection)
    • Anzemet (dolasetron mesylate)
    • Aralast NP
    • Cerezyme
    • Cimzia
    • Cinryze® (C1 esterase inhibitor- human)
    • Elelyso
    • Emend (fosaprepitant dimeglumine)
    • Entyvio
    • Glassia
    • H.P. Acthar Gel (repository corticotrophin injection)
    • Hyaluronate Preparations for Osteoarthritis of the Knee
    • Ilaris
    • Keytruda
    • Lemtrada
    • Lumizyme
    • Myozyme
    • NPlate
    • Opdivo
    • Orencia
    • Prolastin-C
    • Prolia
    • Remicade
    • Rituxan
    • Simponi Aria
    • Soliris
    • Stelara
    • Tysabri
    • VPRIV
    • Xgeva
    • Xolair (omalizumab)
    • Yervoy (ipilimumab)
    • Zemaira
  • Shoulder Arthroscopy
  • Sinus Surgeries
  • Sleep Diagnostics (polysomnography) and Sleep Therapy Management including:
    • Home or Attended Sleep Studies
    • Initiation of Sleep Therapy including Positive Airway Pressure (e.g., CPAP, BiPAP) Titration
    • Purchase of Sleep Therapy (PAP) Equipment
  • Spine Surgeries including:
    • Artificial Cervical Disc
    • Lumbar Decompression
    • Lumbar Fusion (Single and Multiple Level)
    • Lumbar Microdiscectomy
  • Surgical Treatment of Obstructive Sleep Apnea (MMO or UPPP)
  • Treatment of Varicose Veins
  • Urinary Incontinence Surgeries
  • New Technologies that have not been assessed and incorporated into Harvard Pilgrim benefits

For members enrolled in Core HMO products, Harvard Pilgrim also requires prior authorization for Elective Referrals to Non-Contracted Providers.

Questions about Harvard Pilgrim's Utilization Review processes and/or the prior authorization of care
Call Harvard Pilgrim Member Services at 888-888-4742. (For TTY service, please call 711.)
Initial inquiries are referred to Member Services for review and response where appropriate. Routine inquiries regarding specific cases are triaged by Member Services and referred to appropriate Utilization Management (UM) staff via voice mail. UM Staff are available Mon.–Fri., 8:30 a.m.–5:00 p.m.
Inquiries received outside normal business hours are recorded on voice mail and returned within one business day of receipt.

Questions about UM of behavioral health services
Call United Behavioral Health via Harvard Pilgrim's Behavioral Health Access Center at 888-777-4742.

Questions about UM of Outpatient Imaging Services, Interventional Pain Management for Back Pain, or Lumbar Spine Surgeries
Call National Imaging Associates (NIA) at 800-642-7543.

Questions about UM of Sleep Studies and Therapy Management
Call CareCore National (CCN) at 888-511-0401.